Attachment 4 MiscellaneousForms.pdf
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- Attached to
- Building 2-3 Roof Replacement (Morris, MN) Federal contract opportunity
- Solicitation number
- 1232SA26Q0146
About this file
This is Attachment 4 containing miscellaneous forms for the Building 2-3 Roof Replacement project at the North Central Soil Conservation Research Laboratory (NCSCRL), USDA-ARS, Morris, Minnesota. The attachment includes four required forms: Material Approval Submittal form, Schedule of Material Submittals, Recently Replaced Component form, and AD-107 form (Report of Transfer or Other Disposition or Construction of Property).
The Material Approval Submittal form requires contractors to document all material submittals for review and approval by the Architecture & Engineering firm (A&E), Contracting Officer's Representative/Engineering Project Manager (COR/EPM), and Contracting Officer. Each submittal must include specification section references, material descriptions including type/model/manufacturer, and certifications that materials comply with contract specifications. The form provides columns for recommendations and approvals/disapprovals at three review levels, with space for comments. If items are disapproved, resubmittals are required within a specified number of calendar days. The Schedule of Material Submittals identifies 20 line items requiring submission, including construction schedule, daily reports, project records, waste documentation, warranties, O&M manual, and roofing system components (system, insulation, fasteners/hardware, and tampers/crickets), along with a dust mitigation plan and closeout forms. The Recently Replaced Component form documents old and new equipment/systems with details on installation year, location, quantity, serial numbers, model, and manufacturer. The AD-107 form is a USDA property disposition report used to record property transfers or construction activities, requiring signatures from property and fiscal officers with authorization references and inventory values.
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Attachment 4:
Miscellaneous Forms
Building 2-3 Roof Replacement North Central Soil Conservation Research Laboratory (NCSCRL) USDA-ARS, Morris, MN
Building 2-3 Roof Replacement North Central Soil Conservation Research Laboratory (NCSCRL) USDA-ARS, Morris, MN
Notes:
1. The following attachments follow:
a. Material Approval Submittal form
b. Schedule of Material Submittals
c. Recently Replaced Component form
d. AD-107 form
2. Regarding “Material Approval Submittal” form; Contractor shall complete and include this form on each material submittal provided in this project. See “Schedule of Material Submittals” for additional information.
3. Regarding “Schedule of Material Submittals”; schedule indicates a listing of material and information submittals required in the project.
4. Regarding “Recently Replaced Component Form”; Contractor shall complete (with Government assistance) this form and submit to the Government as part of project closeout.
5. Regarding “AD-107” form; Contractor shall complete (with Government assistance) this form and submit to the Government as part of project closeout.
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
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 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)
Building 2-3 Roof Replacement USDA-ARS-NCSCRL, Morris, MN
N-A
N-A
N-A
N-A
Wayne.Myers Underline
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)
SCHEDULE OF MATERIAL SUBMITTALS
PROJECT NUMBER:
PROJECT TITLE: Building 2-3 Roof Replacement USDA‐ARS‐NCSCRL, Morris, MN
SOLICITATION/CONRTACT NUMBER:
TO BE COMPLETED BY COR TO BE COMPLETED BY CONTRACT ADMINISTRATOR
LINE NO.
SOW /PWS/
SPECIFICATION NO: ITEM CE
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SUBMISSION
DATE
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DATE
CONTRACTING
OFFICER
RECEIVED
RETURN
SUSPENSE DATE
DATE
CONTRACTOR
NOTIFIED
APPROVED
(INSERT
SUBMITTAL
NUMBER)
DISAPPROVED
(INSERT
SUBMITTAL
NUMBER)
CONTRACTOR
RESUBMITTAL FINAL APPROVAL REMARKS
Specification Section
01 32 00 Construction Schedule X
Specification Section
01 32 00 Daily Construction Reports X
Specification Section
01 77 00 Project Record Documents X
Specification Section
01 77 00 Documentation on Diverting Project Waste to Recycle
X
Specification Section
01 77 00 Project Warranties X
Specification Section
01 78 00 Project O&M Manual X
Specification Section
07 53 23 Roofing System and components X X X
Specification Section
07 53 23 Roofing insulation system X X X
Specification Section
07 53 23 Roofing insulation fasteners / mounting hardware
X X X
Specification Section
07 53 23 Roofing tamper and crickets X X X
Scope of Work Description
Dust Migitation and Containment Plan X
19 Attachments Recently Replaced Component Form X 20 Attachments AD‐107 X
BUILDER Facility Condition Assessments Recently Replaced Component Form (Not Repairs)
Location/Site name:
Building (CPAIS Asset ID):
Submitted by:
Contact information:
System Equipment Year Installed Location/Room Quantity/Area
Serial Number Model Manufacturer Comments Attachments
Old item
New item
Old item
New item
Old item
New item Notes: 1. If the equipment is not replacing another piece of equipment please use the new installation form
2. Please use this form for equipment replacements as well as building improvements (i.e. roofing, window, or facade replacement projects) greater then $75,000
3. Please provide a PDF of any documents associated with the new install
4. Some columns may not be applicable depending on what is being added
5. If you have suggestions on improvements/questions regarding this form email them to Joshua.Nye@USDA.GOV or call 301-504-1173
Date: ______________________ mailto:Joshua.Nye@ARS.USDA.GOV Joshua.Nye Stamp
Joshua.Nye Stamp
Joshua.Nye Stamp
Here is an example of an attached Word Doc converted into adobe where we can add details and additional information. PDF items can be attached, other formats will need to be converted to adobe.
Joshua.Nye File Attachment Example attachement.pdf
United States Department of Agriculture
Report of Transfer or Other Disposition or Construction of Property
Report No.
Date
3. Proceeds Received
1. Type of Transaction (Report each type separately)
Transfer Sale Trade In Donation
Construction Rehab As-Is
2. Authorization Reference
4. Reporting Agency 5. Receiving Agency (Or Name of Purchaser or Donee)
A. Organizational Unit
B. Location
C. Signature
D. Title
A. Organizational Unit (Or Address of Purchaser)
B. Location
C. Signature
D. Title E. Date
6. Property Items
Quantity (Or Prop. No.)
Item Description (Give Full Details Including Serial Numbers, If Any, and Condition Code)
Inventory Value
Certifications of Property and Fiscal Officers
7. Property Officer: This transaction is completed and the necessary entries have been made to adjust the property records proceeds, if any, are to be deposited to:
Signature Date
8. Fiscal Officer
The sum indicated below has been received in payment for the property disposed of.
A.
B. The necessary entries have been made to adjust the accounting records.
Amount Schedule No.
Signature Date
Form AD-107 (11/89)This form was electronically produced by USDA/ARS/OCIO/EASB.
E. Date
| LocationSite name: |
| Building CPAIS Asset ID: |
| Submitted by: |
| Contact information: |
| EquipmentOld item: |
| Year InstalledOld item: |
| LocationRoomOld item: |
| QuantityAreaOld item: |
| Serial NumberOld item: |
| ModelOld item: |
| ManufacturerOld item: |
| CommentsOld item: |
| EquipmentNew item: |
| Year InstalledNew item: |
| LocationRoomNew item: |
| QuantityAreaNew item: |
| Serial NumberNew item: |
| ModelNew item: |
| ManufacturerNew item: |
| CommentsNew item: |
| EquipmentOld item_2: |
| Year InstalledOld item_2: |
| LocationRoomOld item_2: |
| QuantityAreaOld item_2: |
| Serial NumberOld item_2: |
| ModelOld item_2: |
| ManufacturerOld item_2: |
| CommentsOld item_2: |
| EquipmentNew item_2: |
| Year InstalledNew item_2: |
| LocationRoomNew item_2: |
| QuantityAreaNew item_2: |
| Serial NumberNew item_2: |
| ModelNew item_2: |
| ManufacturerNew item_2: |
| CommentsNew item_2: |
| EquipmentOld item_3: |
| Year InstalledOld item_3: |
| LocationRoomOld item_3: |
| QuantityAreaOld item_3: |
| Serial NumberOld item_3: |
| ModelOld item_3: |
| ManufacturerOld item_3: |
| CommentsOld item_3: |
| EquipmentNew item_3: |
| Year InstalledNew item_3: |
| LocationRoomNew item_3: |
| QuantityAreaNew item_3: |
| Serial NumberNew item_3: |
| ModelNew item_3: |
| ManufacturerNew item_3: |
| CommentsNew item_3: |
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