Exhibit 8 Contract Closeout Compliance Checklist and PSC form.pdf

EXHIBIT 8

Contract Closeout Compliance Checklist and Project Substantial Completion Notice Form

This checklist is intended to assist Agency and Contractor in complying with the Contract Closeout and Final Payment requirements in the General Conditions for Public Improvement Contracts, Sections K and E.6.

Owner will mark “NA” by any requirement that is not applicable to the Contract. Contractor’s and Owner’s

Authorized Representatives shall place their initials by each requirement listed below that has not been marked “NA” by Owner, and provide a Signature at the end of the Checklist.

Keep a copy of the signed form in the Contract Administration file.

Requirements Mark NA if not applicable

Date completed

Contractor initials

Owner initials

K.1 Record Documents submitted

K.2 O & M Manuals submitted per section 01 78 20 of specifications section.

K.3 Certification/Release of Claims

By Contractor’s Signature below, Contractor certifies and agrees to the following:

All Subcontractors and suppliers have been paid in full or will be paid in full out of the final payment, and in compliance with all prompt payment requirements. All disputes with property owners have been resolved, all obligations on the project have been satisfied, all monetary claims and indebtedness have been paid, and, to the best of the Contractor's knowledge, there are no claims of any kind outstanding against the project.

K.4 Completion notices submitted

Substantial Completion notice Date of substantial completion:

Contract Number 182502 Contract Name Seclusion Room Renovation, Oregon State Hospital, Junction City Contractor Owner’s Authorized Rep. Joel Turner, Project Manager

K.5 Owner training sessions scheduled

K.6 Extra materials provided per project specifications:

Flooring Paint Wiring devices

K.7. Environmental Clean-up:

Contractor hereby notifies Owner that all environmental cleanup that was performed as a part of this contract has been disposed of in accordance with all applicable rules, regulations, laws, and statutes of all agencies having jurisdiction over such environmental pollution.

K.8 Certificate of Occupancy received by Owner

K.9 Complete and submit Facilities Planning and Safety Project Substantial Completion Notice Form.

This includes the following process:

□ FPS completes an onsite inspection;

□ All deficiencies identified during inspection have been resolved;

□ FPS issues a final Notice of Project Approval; and

□ All OHA Health Facility Licensing and

Certification requirements or All DHS Safety, Oversight and Quality Unit requirements have been met.

E.6 Contractor’s final payment request submitted

Final payment request approved by Owner

CONTRACTOR’S AUTHORIZED REPRESENTATIVE:

Printed Name Title

Signature Date

OWNER’S AUTHORIZED REPRESENTATIVE:

PUBLIC HEALTH DIVISION, Center for Health Protection Health Care Regulation and Quality Improvement Section Health Facility Licensing and Certification Program

Facilities Planning & Safety Unit

Tina Kotek, Governor

Printed Name Title

Signature Date

Project Substantial Completion Notice Form

Use this form for: Hospitals (including Hospital Satellites), End-Stage Renal Dialysis

Facilities, Ambulatory Surgery Centers, Special Inpatient Care Facilities and Birthing Centers licensed by OHA Health Facility Licensing and Certification.

-or- Nursing Homes, Assisted Living Facilities and Residential Care Facilities licensed by DHS Safety, Oversight and Quality Unit.

INSTRUCTIONS:

To request an onsite inspection by Facilities Planning and Safety (FPS), please complete and return this form as directed below approximately three (3) weeks prior to receiving an Occupancy Permit from the authority having jurisdiction.

FPS will contact you directly to coordinate an onsite inspection date.

PLEASE NOTE:

Patients may not occupy the space until the following steps have been completed:

□ FPS completes an onsite inspection;

□ All deficiencies identified during inspection have been resolved;

□ FPS issues a final Notice of Project Approval; and

□ All OHA Health Facility Licensing and Certification requirements or All DHS Safety, Oversight and Quality Unit requirements have been met.

PR# 21-160 Date: Enter today’s date.

Project Name: OSH Junction City Seclusion Room Renovation.

Project Description: (2) Seclusion rooms with toilet and ante rooms on floors 1-2

Project Address: 92213 Dreas Way, Junction City OR 97448

Expected Occupancy Date: Enter provider’s expected occupancy date.

#1 Requested Inspection Date: Preferred FPS inspection date.

#2 Requested Inspection Date: Alternative FPS inspection date.

Facility Contact: Joel Turner Email joel.t.turner@oha.oregon.gov Phone (desk): (503) 947-8157 Cell: (503) 881-3379 Design Team Contact: Jon Mehlschau Email Enter email address.

Phone (desk): Enter office phone number. Cell: Enter cell phone number.

Distribute copies of this completed form as follows:

ALL projects, submit one (1) copy to:

Facilities Planning & Safety Oregon Health Authority – Public Health 800 NE Oregon Street, Suite 465 Portland, OR 97232 Phone: (971) 673-0540 Fax: (971) 673-0556 mailbox.fps@odhsoha.oregon.gov

ALL projects, submit one (1) copy to:

The City, County or State Building Codes Agency that issued the Building Permit for the project.

Nursing Homes, submit one (1) copy to:

Safety, Oversight and Quality Unit PO Box 14530 Salem, OR 97309 Phone: (503) 373-3227 NF.licensing@odhsoha.oregon.gov

Residential Care Facilities and Assisted Living Facilities, submit one (1) copy to your assigned licensing policy analyst at:

Safety, Oversight and Quality Unit PO Box 14530 Salem, OR 97309

Vickie Surico, Victoria.S.Surico@odhsoha.oregon.gov (971) 283-6116 Becky Mapes, Rebecca.MAPES@odhsoha.oregon.gov (503) 373-2076 Warren Bird, Warren.D.BIRD@odhsoha.oregon.gov (503) 373-1959 Kimberly Hector, Kimberly.S.Hector@odhsoha.oregon.gov (503) 373-0246 Meghan McClain, Meghan.K.Nielson@odhsoha.oregon.gov (503) 979-9635 Cassie Studer, Cassie.Studer@odhsoha.oregon.gov (503) 979-6073 mailto:mailbox.fps@odhsoha.oregon.gov mailto:NF.licensing@odhsoha.oregon.gov mailto:Victoria.S.Surico@odhsoha.oregon.gov mailto:Rebecca.MAPES@odhsoha.oregon.gov mailto:Warren.D.BIRD@odhsoha.oregon.gov mailto:Meghan.K.Nielson@odhsoha.oregon.gov mailto:Cassie.Studer@odhsoha.oregon.gov