Attachment 7 - USDA Forms 02AUG2023.pdf

FORMS

Current as of August 2, 2023

HOT WORK PERMIT

NEEDED WHEN ANY SPARK OR HEAT PRODUCING EQUIPMENT IS TO BE USED

Project Name:

Name of Contractor’s Firm:

Contractor Contact Name:

Contractor Contact Telephone Number

Date:

Building/Location:

Work To Be Done:

Any Special Precautions:

Fire Watch Required: Yes No The location where the work is to be performed has been examined, necessary precautions have been taken, and permission is granted for this work.

Signed (Contractor Individual Responsible for Authorizing Hot Work)

Permit Expires: (Date)

Time Hot Work Started: Time Hot Work Completed:

FINAL CHECK-UP

Work area and all adjacent areas to which sparks and heat might have spread (including floors above and below and on opposite sides of walls) were inspected 30 minutes after the work was completed and were found fire safe.

Signed _ Contractor’s Fire Watch)

(Page 1 of 2)

Date _

ATTENTION

Before approving any cutting and welding permit, the contractor’s authorized representative or their appointee shall inspect the work area and confirm that precautions have been taken to prevent fire in accordance with NFPA Standard No. 51B.

PRECAUTIONS

• Sprinklers are in service where installed

• Cutting and welding equipment in good repair

• Within 35 feet; floors swept clean of combustible, no combustible material or flammable liquids, all wall and floor openings covered, and covers suspended beneath work to collect sparks

• When working on enclosed equipment and in confined space, equipment and area is free of flammable vapors

• Fire watch provided during and 30 minutes after operation (60 minutes for torch applied roofing operations)

• Portable fire extinguisher with adequate rating available in the immediate vicinity

• Standpipe system in service where installed

• Protection of any sprinkler heads when hot work is in close proximity

• Smoking prohibited in immediate vicinity

• Non-combustible shields provided when hot work is done near combustible walls, partitions, floors, roofs

• Prohibition of hot work on pipes contacting combustible walls

• Personnel trained in use of equipment including portable fire extinguishers and sounding a fire alarm

• Final check-up conducted after 30 minute

(Page 2 of 2)

DAILY INSPECTION FORM

INSTRUCTIONS: This form is to be utilized when hazards are posed by NFPA 101 deficiencies or construction activities are in progress. Remediation must be implemented upon project start and continuously enforced through project completion to provide a level of life safety comparable to that described in the Life Safety Code. Submit completed forms to the Contracting Officer.

Project Name: Project Number:

Construction & Impact Description: Construction Location:

Affected Areas:

Project COR: Project Start Date:

Project Competent Person (CP): Estimated Duration:

Completion Date:

Contractor:

GC Supervisor: Telephone:

Contractor CP:

Inspection Period:

Responses: SUN MON TUE WED THR FRI SAT

1. Are exits readily accessible and provide unobstructed egress?

2. Have alternate exits been established if required due to

3. If alternate exits have been established, are personnel in the area informed and aware of their relocation?

4. Are the existing and relocated exits clearly marked and able to be

5. Are evacuation routes posted with follow-up inspections required

6. Are written procedures and guidelines posted in the immediate and adjacent areas for what to do and who to call in the event of a fire

7. Are personnel in immediate/adjacent areas aware and informed in procedures and guidelines to follow in the event of fire

8. Is there free and unobstructed access to services for emergency personnel (eg, fire, medical, security)?

9. Are fire alarm (eg, pull station), detection (eg, smoke/heat), suppression (eg, sprinkler, extinguisher) systems in working

10. If the fire alarm, detection, suppression systems are impaired or temporarily non-functional, has a fire watch for the area, as required or necessary, been trained and established?

11. If the fire alarm, detection, suppression systems are impaired, have measures been taken to provide temporary equivalent equipment and/or systems for adequate protection? Note date for

12. If the fire alarm, detection, suppression systems are impaired, are equivalent equipment/systems inspected and tested

13. If temporary fire alarm, detection, suppression systems are installed, are personnel in the area aware and trained on how to operate or utilize them in the event of fire or emergency?

14. Has the “No Smoking” policy been posted, implemented and enforced in the construction area?

15. Are temporary partitions built to be fire/smoke tight with fire retardant noncombustible material and inspected daily for

16. Is construction site access restricted to authorized personnel only including warning signs and secured at the end of each

Inspection Period:

Responses:

SUN

MON

TUE

WED

THR

FRI

SAT

17. Is construction area hazard surveillance conducted daily?

18. Is construction area storage, waste, debris and excess materials being daily managed properly to reduce fire or safety

19. Are construction activities and materials prosecuted, handled, stored, and secured in an orderly and safe manner?

20. Is the generation, spread and exposure of construction dust, fumes, noise, odor, smoke controlled with appropriate fume, odor, vapor ventilation provided to control noxious, infectious, toxic exposure and store/protect flammable/combustible products?

21. Has a GC Safety Manager been designated with routine site safety meetings conducted to ensure awareness of Life Safety

22. Is personnel protective equipment (e.g., safety glasses, ear plugs, hard hats) required and being used?

23. If there are hand/safety rails, scaffolding or ladders required, are they in place, in good condition and being used in a

24. Are the construction site (buildings and exterior grounds) hazards (e.g., fall/trip) guarded and free of potential safety

25. Do electrical panels, temporary wiring, extension cords (3 wire grounded type), tools, and equipment appear to be installed, utilized, and functioning in a safe manner?

26. If there are temporary electrical outlets provided, do they have ground fault protection at the receptacle/panel?

27. If hazardous equipment/systems need to be de-energized, are applicable “Lockout/Tagout” procedures being followed?

28. Are utility services (e.g., electrical, steam, water, waste, gas) properly secured at the end of each day?

29. If there is any hot work (welding, soldering, cutting) being performed within the construction site, have additional fire safety precautions been taken and necessary equipment provided?

30. If there is any hot work (welding, soldering, cutting) being performed on the construction site, has Contracting Officer been notified? Has the Hot Work Permit been approved?

31. If hazardous products are present, are they limited to the amount needed and used daily?

32. Are hazardous products disposed according to EPA

33. Are all hazardous products present or being used (e.g., flammable, combustible, corrosive, noxious) labeled with MSDS information readily available?

34. If infection control is required, are the appropriate policies and procedures known and being followed?

35. Are all safety incidents documented and reported to the Contracting Officer?

Contractor CP Initials Performing Daily Inspections:

Inspection Comments/Findings: (PROVIDE DETAILED EXPLAINATION OF

EXCEPTIONS/DEFICIENTIES)

Signature/Date:

Project CP GC Safety Manager

U.S. DEPARTMENT OF AGRICULTURE • AGRICULTURAL RESEARCH SERVICE IMPORTANT: Read instructions on reverse before completing this form.

DESCRIPTION OF

BRANCH OF WORK

PROGRESS SCHEDULE SCHEDULE OF PAYMENTS

(Use in conjunction with ARS Form 372)

Value Percent of work

DATE Completed this period

Previously Completed

Total CompletedStart Complete

A B C D E F G 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

Following items to be used for Change Orders, Amendments, and other.

24.

25.

26.

27.

28.

29.

30.

31.

TOTAL

CONTRACT NO. AMOUNT STARTING DATE COMPLETION DATE

PROJECT

LOCATION

CONTRACTOR'S NAME & ADDRESS (Include Zip code)

REMARKS

CONTRACTOR'S SIGNATURE DATE CONTRACTING OFFICER'S APPROVAL DATE

Form ARS-371 (11/84) Previous edition may be used. USDA-ARS

CONSTRUCTION PROGRESS AND PAYMENT SCHEDULE

CALENDAR DAYS

This form was electronically produced by USDA/ARS/OCIO/EASB.

INSTRUCTIONS FOR COMPLETION OF FORM ARS - 371

The construction Progress - Payment Schedule shall be submitted within 14 calendar days after the date of receipt of Notice to Proceed.

This form is required even though partial payments are not requested. If partial payments are requested, a copy of the approved Form ARS-371 must accompany each Payment Request (Form ARS-372), and Columns E, F, and G must be filled in according to the work completed.

Complete blocks entitled: Contract Number, Amount, Calendar Days, Starting Date, Completion Date, Project, Location, and Contractor's Name and Address.

Complete Column A, Value, indicating a complete breakdown of each branch of work in dollar value.

Complete Column B, Percent of Work, showing the percentage of each branch of work in relation to the whole project.

Complete Columns C and D to show the approximate dates each branch of work will begin and be completed. Final completion date in Column D must not exceed the completion date at the top of the form.

Contractor shall sign the form at the bottom and submit to the Contracting Officer for his approval. An approved copy will be returned to the Contractor for his file.

1.

2.

3.

4.

5.

Form ARS-371 (Reverse)

CONTRACTOR'S REQUEST FOR PAYMENT TRANSMITTAL

CONTRACT NO.

PROJECT

LOCATION

PARTIAL PAYMENT NO.

REQUISITION NO.

FOR PERIOD BEGINNING ENDING

FINAL PAYMENT

ITEM AMOUNT

1. Amount of original contract

2. Change orders and/or amendments

3. Total adjusted contract prices

4. Value of work completed to end of period

5. Value of material stored at the site (Itemize below)

6. Total value of work completed and stored material (Line 4 plus Line 5).

8. Total due contractor thru end of this period

9. Less previous requests

10. Net amount due contractor this payment

7. Less % retainage

MATERIAL STORED AT THE SITE (See Item 5 above)

Description Value

CONTRACTOR'S CERTIFICATION OF PAYMENT

By signing this request for payment, I certify that I have made payment from the proceeds of prior payments, and that I will make timely payment from the proceeds of this payment, of amounts due my subcontractors and suppliers in accordance with my con-tractual arrangements with them.

SIGNATURE OF CONTRACTOR'S AUTHORIZED REPRESENTATIVE

RECOMMENDED FOR PAYMENT (Signature of EPM, COR, CM or A.E. as ppropriate)

CONCUR (Signature of EPM or COR as appropriate)

DATE SIGNED

DATE SIGNED

DATE SIGNED

Form ARS-372 (11/84) Replaces SEA-372 (1/79) which may be used. USDA-ARS This form was electronically produced by USDA/ARS/ITD using InForms software.

MATERIAL APPROVAL SUBMITTAL

TO: USDA/ARS CO

CC: A&E, COR

FROM: (Contractor) PROJECT TITLE: CONTRACT NUMBER:

(To be completed by the Contractor) Government Use Only

SUBMITTAL

NUMBER:

PREVIOUS SUBMITTAL NUMBER

(only if items listed were submitted previously):

A&E Recommendation

COR/EPM

Recommendation

Contracting Officer Approval/Disapproval

Line No.

Specification Sect.

Para No., Draw No.

Description of Material (Include type, model, mfg) APP DISAP

See Comments on Reverse APP DISAP

See Comments on Reverse APP DISAP

See Comments on

Reverse

If an item is disapproved, a resubmittal is due within ________ calendar days of the Contracting Officer’s signature below.

Contractor (Ktr) A&E COR/EPM Contracting Officer TYPE or PRINT NAME & TITLE TYPE or PRINT NAME & TITLE TYPE or PRINT NAME & TITLE TYPE or PRINT NAME & TITLE

SIGNATURE: SIGNATURE: SIGNATURE: SIGNATURE:

DATE: DATE: DATE: DATE:

By completing this form, the above signed contractor certifies that the material complies with all specifications of the subject contract.

DATE RECEIVED FROM KTR: DATE RECEIVED FROM A&E: DATE RECEIVED FROM COR:

Material Approval Submittal Cover Sheet (11/2016)

CONTRACT #: SUBMITTAL #:

COMMENTS

Instructions: Enter the initials of the individual making the comment, the Line Number of the item for which the comment is being made, and the comment.

Material Approval Submittal Cover Sheet (11/2016) (Reverse)

CALCULATION OF SELF‐PERFORMED/SUBCONTRACTED WORK

Offerors for NAICS 236xxx must provide 15%, NAICS 237xxx and 238xxx 25% of the cost of the contract performance incurred for personnel will be spent on the concern's employees or the employees of other small business concerns. Provide a breakdown of material and personnel costs, by specification division listed for the project. Home Office overhead, profit/fee and bond costs shall be added after a subtotal of personnel and material/Equipment costs has been calculated. Clearly identify the personnel costs you will be performing, and the personnel costs of other eligible small business concerns. Below is a suggested format.

Specification Division SB Vendor (Y or N) Personnel Cost Material/Equipment Costs

Division 01 $ $

Division 02 $ $

Division 03 $ $

(Add additional lines as necessary for each Division applicable to this project)

Sub Total (Personnel Costs, Material/Equipment Costs)

Profit $

Home Office Overhead $

Bond $

Grand Total $

Calculation of self‐performed personnel costs:

1. Total personnel costs * both prime and all subcontractors: $

2. Subtract all subcontractor personnel costs* that are not SB companies that will perform work on this contract: $

3. Remainder is ‘Total amount of work to be self‐performed under the Contract’: $

4. Self‐performed work = Line 3/Line 1 x 100 = %

*personnel costs include labors, mechanics, other tradesmen, and office personnel directly charged to the project (includes project manager, job superintendent, administrative, estimators, etc.)

I certify the above representations are true and correct to the best of my knowledge.

(Signature and Typed Name of Authorized Representative) Date

(Title of Authorized Representative)

Contractor Certification Regarding Project: Project Title Here

2020 2021 2022 2023

Number of serious, willful, or repeat violations from OSHA within the last 3 years. Please attach explanation for any violations. (Four serious, one repeat, or one willful violation could result in being determined non-responsible.)

Company’s Current Insurance Experience Modification Rate (EMR) = _____________

(Note: Contractor must support the EMR with a signed letter from Insurance Carrier on their letterhead.)

Signature: ______________________________________________

Typed Name: ______________________________________________________

Title: ______________________________________________________