SOW Attachment 9 - Sample Forms.pdf

SPECIFICATION

PARAGRAPH

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

DIVISION 1-GENERAL REQUIREMENTS

01 30 00 Administrative Requirements

1.3 List of contact personnel X X x

1.1 View location map X x

1.1 Progress and Completion Pictures X x

1.14 As-built drawings within 15 days after acceptance of job

1.6 Utililty locates 7 days prior, 30 days for power shut off

01 32 01 Project Schedule

1.2 Preliminary Project Schedule X X X x

1.2 File naming Convention X X X X

1.2 Initial Project Schedule x NTP+45 days

1.2 Periodic Schedule Updates X X X every month

01 35 26 Government Safety Requirements

1.2 Accident Prevention Plan (APP) x x x x x

1.2 Crane Critical Lift Plan x x x x x

1.2 Activity Hazard Analysis (AHA) x x x x

1.2 Emergency Response Plan

1.2 Fall Protection and Prevention Plan x x x x x

1.2 Qualification of Competent Person x x x x x

1.2 Qualification of Site Safety and Health Officer x x x

1.2 Excavation Permit x x x x

1.2 Licenses, Permits and Notifications x X x x

1.2 Accident Reports x x

USACE Prime Contractor Monthly Record of Work-Related Injuries/Illnesses &

Safety Exposure Reports

1.2 Regulatory Citations and Violations x x x

1.2 Summary of Worker Compensation Claim x x x

1.2 Confined Space Entry Permit x x x x

1.2 Hot Work Permit x x x

1.2 License Certificates x x x x x

1.2 Excavator Certificate of Compliance x x

01 45 01 Quality Control

1.4 Quality Control Plan x x x x x

1.4 Daily Contractor Quality Control Reports (CQC) x x

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

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1.2 x x x

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ENG FORM 4288, Jul 96 01 33 00-1A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

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C E R T I F I C A T E S

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01 45 35 Special Inspection for Seismic-Resisting Systems

1.3 Certification for Qualification of Special Inspector x x x

1.3 QC Plan covered with a Certificate x x x

01 50 00 Temporary Facilities and Controls

1.3 Construction Site Plan x x x x

01 57 20.00 10 Environmental Protection x x x x x x x x x x x x

01 57 23 Temporary Storm Water Pollution

1.4 Storm Water Pollution Prevention Plan x x

1.4 Storm Water Notice of Intent x x

1.4 Storm Water Inspection Reports for General Permit x

1.4 Certificate Attesting Met All Requirements x

01 74 19 Construction and Demolition Waste Management x x x

1.5 Monthly Construction & Demolition Debris Diversion and Disposal x x x

01 78 23 Operation and Maintenance Data

1.2 Operations and Maintenance Data x x x

1.2 Manufacturer’s Instructions x x x

01 78 29 Final Site Survey

1.2 Final Cleaning x x x

1.4 Environmental Protection Plan

1.4 Condition Survey Reports

1.4 Hazardous Waste Manifests

1.4 Non-Hazardous Solid Waste Diversion Report

1.5 Demolition Debris Management Plan

1.2 Spare Parts Data

ENG FORM 4288, Jul 96 01 33 00-2A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

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R E P O R T S

01 78 29 Warranties

1.2 Warranty Tags x x x

Warranty Management Plan x x x

01 78 39 Project Record Documents

1.1 As-Built Record of Equipment and Materials x x x

1.1 Record Drawings x x x

DIVISION 03-CONCRETE

03 30 53 (Short Form) Cast-in-Place Concrete

1.5 Concrete Mix Design x x x

1.5 Shop Drawings: Reinforcing Steel x x

1.5 Manufacturer's Certificates x x

DIVISION 04-MASONRY

04 05 13 Masonry Mortaring

1.5 Certificates x x

1.5 Laboratory Test Reports x x

1.5 Manufacturer's Literature and Data x x

04 05 16 Masonry Grouting

1.4 Certificates x x

1.4 Laboratory Test Reports x x

1.4 Manufacturer's Literature and Data x x

04 20 00 Unit Masonry

1.3 Samples x x

1.3 Shop Drawings x x

1.3 Certificates x x

1.3 Manufacturer's Literature and Data x x

04 73 00 Simulated Stone

1.3 Samples x x

1.3 Shop Drawings x x

1.3 Certificates x x

1.3 Manufacturers Test Results x x

ENG FORM 4288, Jul 96 01 33 00-3A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

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D A T A

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A P P R O V E D

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C E R T I F I C A T E S

R E P O R T S

1.3 Laboratory Data x x

1.3 List of Jobs Furnished by Manufacture x x

DIVISION 05- METALS

05 12 00 Structural Steel Framing

1.6 Shop and Erection Drawings x x

1.6 Certificates x x

1.6 Test Reports

1.6 Record Surveys x x

x x

05 36 00 Composite Metal Decking

1.4 Shop Drawings x x

1.4 Manufacturer's Literature and Data x x

1.4 Manufacturer's Written Recommendation x x

1.4 Test Report x x

1.4 Shear Stud Layouts x x

1.4 Certifications x x

05 40 00 Cold-Formed Metal Framing

1.4 Shop Drawings x x

1.4 Manufacturer's Literature and Data x x

05 50 00 Metal Fabrications

1.3 Manufacturer's Literature and Data x x

1.3 Shop Drawings x x

1.3 Manufacturer's Certificates x x

1.3 Design Calculations x x x

1.3 Furnished Setting Drawings and Instructions x x x

DIVISION 06-WOOD, PLASTICS, AND COMPOSITES

06 10 00 Rough Carpentry

1.3 Shop Drawings x x

06 16 63 Cementitious Sheathing

1.2 Samples x x

ENG FORM 4288, Jul 96 01 33 00-4A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

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A P P R O V E D

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O& M

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C E R T I F I C A T E S

R E P O R T S

1.2 Product Data x x

06 20 00 Finish Carpentry

1.3 Shop Drawings x x

1.3 Samples x x

1.3 Certificates x x

1.3 List of Acceptable Sealers x x

1.3 Manufacturer's Literature and Data x x

06 65 00 Solid Polymer Fabrications

1.4 Manufacturer's Literature and Data x x

1.4 Samples x x

1.4 Shop Drawings x x

1.4 Maintenance Data x x

DIVISION 07- THERMAL AND MOISTURE PROTECTION

07 21 13 Thermal Insulation

1.3 Manufacturer's Literature and Data x x

1.3 Certificates x x

07 22 00 Roof and Deck Insulation

1.4 Manufacturer's Literature and Data x x

1.4 Samples x x

1.4 Certificates x x

1.4 Laboratory Test Reports x x

1.4 Layout of Tapered Roof System x x

1.4 Documentation of Supervisors Training & Experience x x

07 46 40 Mineral Fiber Cement Siding

1.2 Samples x x

1.2 Product Data x x

07 51 00 Build-Up Bituminous Roofing

1.6 Product Data x x

1.6 Certificates x x

1.6 Warranty x x

ENG FORM 4288, Jul 96 01 33 00-5A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

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C E R T I F I C A T E S

R E P O R T S

07 60 00 Flashing and Sheet Metal

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data x x

07 71 00 Roof Specialities

1.4 Samples x x

1.4 Shop Drawings x x

1.4 Manufacturer's Literature and Data x x

1.4 Certificates x x

07 72 00 Roof Accessories

1.4 Samples x x

1.4 Shop Drawings x x

1.4 Manufacturer's Literature and Data x x

1.4 Certificates x x

07 84 00 Firestopping

1.3 Manufacturer's Literature and Data x x

1.3 List of FM, UL, or WH Classification x x

1.3 Certified Laboratory Test Reports x x

07 92 00 Joint Sealants

1.4 Manufacturer's Installation Instructions x x

1.4 Samples x x

1.4 Manufacturer's Literature and Data x x

07 95 13 Expansion Joint Cover Assemblies

1.5 Manufacturer's Literature and Data x x

1.5 Certificates x x

1.5 Shop Drawings x x

1.5 Samples x x

DIVISION 08- OPENINGS

08 14 00 Interior Wood Doors

1.3 Samples x x

1.3 Shop Drawings x x

1.3 Laboratory Test Reports x x

ENG FORM 4288, Jul 96 01 33 00-6A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

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08 31 13 Access Doors and Frames

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data x x

08 33 13 Coiling Counter Doors

1.3 Manufacturer's Literature and Data x x

1.3 Shop Drawings x x

08 41 13 Aluminum-Framed Entrances and Storefronts

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data x x

1.3 Samples x x

1.3 Manufacturer's Certificates x x

08 71 00 Door Hardware

1.4 Hardware Schedule x x

1.4 Samples and Manufacturers' Literature x x

1.4 Certificates of Compliance and Test Reports x x

08 80 00 Glazing

1.3 Manufacturer's Literature and Data x x

1.3 Warranty x x

1.3 Samples x x

1.3 Manufacturer's Certificates x x

1.3 Preconstruction Adhession and Compatibility Test Report x x

08 90 00 Louvers

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data x x

DIVISION 09- FINISHES

09 22 16 Non-Structural Metal Framing

1.4 Manufacturer's Literature and Data x x

1.4 Shop Drawings x x

1.4 Test Results x x

ENG FORM 4288, Jul 96 01 33 00-7A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

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MA

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C E R T I F I C A T E S

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09 24 00 Portland Cement Plastering

1.4 Manufacturer's Literature and Data x x

1.4 Samples x x

09 29 00 Gypsum Board

1.4 Manufacturer's Literature and Data x x

1.4 Shop Drawings x x

1.4 Samples x x

1.4 Test Results x x

09 30 13 Ceramic Tiling

1.3 Samples x x

1.3 Product Data x x

1.3 Certification x x

09 51 00 Acoustical Ceilings

1.3 Samples x x

1.3 Manufacturer's Literature and Data x x

1.3 Manufacturer's Certificates x x

09 65 13 Resilient Base and Accessories

1.3 Manufacturer's Literature and Data x x

1.3 Samples x x

09 65 16 Resilient Sheet Flooring

1.4 Manufacturer's Literature and Data x x

1.4 Samples x x

09 65 19 Resilient Tile Flooring

1.3 Manufacturer's Literature and Data x x

1.3 Samples x x

1.3 Shop Drawings x x

1.3 Test Reports x x

09 68 00 Carpeting

0.4 Product Data x x

1.4 Samples x x

1.4 Shop Drawings x x

1.4 Maintenance Data x x

ENG FORM 4288, Jul 96 01 33 00-8A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

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D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

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O& M

MA

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C E R T I F I C A T E S

R E P O R T S

09 91 00 Painting

1.3 Manufacturer's Literature and Data x x

1.3 Sample Panels x x

1.3 Sample of Identity Markers x x

1.3 Manufacturers' Certificates x x

DIVISION 10-SPECIALTIES

10 21 23 Cubicle Curtain Tracks

1.3 Samples x x

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data

x x

10 26 00 Wall and Door Protection

1.3 Shop Drawings x x

1.3 Manufacturer's Literature and Data x x

1.3 Test Report x x

10 28 00 Toilet and Bath Accessories

1.5 Manufacturer's Literature and Data x x

1.5 Warranty x x

1.5 Manufacturer's Certificates x x

1.5 Samples x x

1.5 Shop Drawings x x

10 44 13 Fire Extinguisher Cabinets

1.3 Manufacturer's Literature and Data x x

10 70 50 Exterior Sunshades

1.6 Certificates x x

1.6 Samples x x

1.6 Shop Drawings x x

1.6 Design Calculations x x

DIVISION 11- EQUIPMENT

11 73 00 Ceiling Mounted Patient Lift System

ENG FORM 4288, Jul 96 01 33 00-9A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

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MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.4 Certificates of Compliance x x

1.4 Manufacturer's Literature and Data x x

1.4 Individual Room Layouts x x

DIVISION 12- FURNISHES

12 31 00 Manufactured Metal Casework

1.4 Certificates x x

1.4 Manufacturer's Literature and Data x x

1.4 Shop Drawings x x

1.4 Samples x x

12 36 00 Countertops

1.3 Shop Drawings x x

1.3 Samples x x

DIVISION 13- SPECIAL CONSTRUCTION

13 05 41 Seismic Restraint Requirements for Non-Structural Components

1.4 Equipment Anchorage Drawings

1.4 Bracing Drawings for Seismic Protection of Piping

1.4 Seismic Protection of Suspended Ductword and Electrical

13 49 00 Radiation Protection

1.5 Shop Drawings

1.5 Samples

1.5 Manufacturer's Literature and Data

DIVISION 21- FIRE SUPPRESSION

21 05 11 Common Work Results for Plumbing

1.4 Manufacturer's Literature and Data x x

1.4 Coordination Drawings x x

1.4 Maintenance Data and Operating Instructions x x x

21 13 13 Wet-Pipe Sprinkler Systems

1.3 Qualifications x x

1.3 Drawings x x

ENG FORM 4288, Jul 96 01 33 00-10A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.3 Manufacturer's Data Sheets x x

1.3 Calculations Sheets x x

1.3 Final Document Submittals x x

1.3 Design Basis Information x x

x x x x

DIVISION 22-PLUMBING

22 05 11 Common Work Results for Plumbing

1.4 Manufacturer's Literature and Data x x

1.4 Coordination Drawings x x

1.4 Maintenance Data and Operating Instructions x x

22 05 19 Meters and Gages for Plumbing Piping

1.3 Manufacturer's Literature and Data x x

22 05 23 General-Duty Valves for Plumbing Piping

1.3 Manufacturer's Literature and Data x x

22 11 00 Facility Water Distribution

1.3 Manufacturer's Literature and Data x x

22 13 00 Facility Sanitary Sewerage

1.3 Manufacturer's Literature and Data x x

1.3 Shop Drawings of Clamping Device and Extensions x x

22 14 00 Facility Storm Drainage

1.3 Manufacturer's Literature and Data x x

1.3 Shop Drawings of Clamping Device and Extensions x x

22 34 00 Fuel-Fired Domestic Water Heaters

1.4 Water heaters and Associated Accessories x x x x

1.4 Pressure and Temperature Relief Valves x x x x

1.4 Coaxial Vent Piping and Roof Jack x x x x

1.4 Thermometers x x x x

1.4 Pressure Gages x x x x

1.4 Vacuum Breakers x x x x

22 40 00 Plumbing Fixtures

ENG FORM 4288, Jul 96 01 33 00-11A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.3 Plumbing Fixture Information x x x

DIVISION 23-HEATING, VENTILATION, AND AIR CONDITIONING (HVAC)

23 05 11 Common Work Results for HVAC

1.4 Samples x x

1.4 Layout Drawings x x

1.4 Manufacturer's Literature and Data x x

1.4 HVAC Maintenance Data and Operating Instructions x x

1.4 Approved HVAC Equipment x x x

23 05 12 General Motor Requirements for HVAC Equipment

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Certification x x

23 05 41 Noise and Vibration Control for HVAC Piping and Equipment

1.3 Manufacturer's Literature and Data x x

1.3 Load Calculations for Selection of Isolators x x x

1.3 Seismic Requirements x x x x

23 05 93 Testing, Adjusting, and Balancing for HVAC

1.4 Names and Qualifications of TAB Agency and TAB Specialists x x x x

1.4 AABC and NEBB Publications x x x x

1.4 Design Review Report x x

1.4 Systems Inspection Report x x

1.4 Duct Air Leakage Test Report x x

1.4 Systems Readiness Report x x

1.4 Intermediate and Final TAB Reports x x

1.4 Final Reports x x

1.4 Completed Test and Balance Report x x

x x

23 07 11 HVAC, Plumbing, and Boiler Plant Insulation

1.4 Shop Drawings x x x

1.4 Samples x x

23 09 23 Direct-Digital Control System for HVAC

ENG FORM 4288, Jul 96 01 33 00-12A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.6 Manufacturer's Literature and Data x x

1.6 Product Certificates x x

1.6 As Built Control Drawings x x

1.6 Operation and Maintenance (O&M) Manuals x x

1.6 Performance Report for Final Inspection x x

23 11 23 Facility Natural-Gas Piping

1.3 Manufacturer's Literature and Data x x

1.3 Shop Drawings of Clamping Device x x

23 21 13 Hydronic Piping

1.4 Manufacturer's Literature and Data x x

1.4 Manufacturer's Certified Data Report x x

1.4 Certificate of Welder's Certification x x

1.4 Coordination Drawings x x

1.4 As Built Piping Diagrams x x

23 21 23 Hydronic Pumps

1.4 Manufacturer's Literature and Data x x

1.4 Manufacturer's Installation, Maintenance, & Operating Instructions x x

1.4 Characteristic Curves x x x

23 23 00 Refrigerant Piping

1.4 Shop Drawings x x

1.4 Certification x x

23 25 00 HVAC Water Treatment

1.4 Manufacturer's Literature and Data x x

1.4 Water Analysis Verification x x

1.4 Material Safety Data Sheet x x

1.4 Maintenance and Operating Instructions x x

23 31 00 HVAC Ducts and Casings

1.3 Manufacturer's Literature and Data x x

1.3 Coordination Drawings x x

23 34 00 HVAC Fans

1.4 Manufacturer's Literature and Data x x

ENG FORM 4288, Jul 96 01 33 00-13A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.4 Certified Sound Power Levels for each fan x x

1.4 Motor Ratings Types, Electrical Characteristics and Accessories x x x x

1.4 Roof Curbs x x x

1.4 Belt Guards x x x

1.4 Maintenance and Operating Manuals x x

1.4 Certified Fan Performance Curves x x

23 36 00 Air Terminal Units

1.4 Manufacturer's Literature and Data x x

1.4 Certificates x x

1.4 Operation and Maintenance Data x x

23 37 00 Air Outlets and Inlets

1.4 Manufacturer's Literature and Data x x

1.4 Coordination Drawings x x

23 40 00 HVAC Air Cleaning Devices

1.4 Manufacturer's Literature and Data x x

1.4 Air Filter Performance Reports x x

1.4 Suppliers Warranty x x x

1.4 Field Test Results from HEPA Filters x x

x x

23 51 00 Breeching, Chimneys, and Stacks

1.4 Design, Materials, Weights, Construction, Pressure, Temperature Limitations x x x

1.4 Drawings Showing Components, System Arrangement, and Dimensions x x

1.4 Design, Construction, Allowable Movements, Movement Forces, etc. x x x

1.4 Damper Design, Construction, Pressure and Temperature Limitations etc. x x x

1.4 Support Design, Locations, and Loads for Entire Assembly x x x

1.4 Written Statement from Boiler/Burner Manufacture x x

23 52 34 Water-Tube Condensing Boilers

1.4 Boiler x x x

1.4 Burner and Fuel Trains x x x

1.4 Burner Management (Flame Safeguard) Control System x x x

1.4 Seismic Data x x

1.4 Boiler and Burner Predicted Performance Data x x x

1.4 Pretest Data x x

1.4 Final Test Report x x

ENG FORM 4288, Jul 96 01 33 00-14A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

23 64 00 Packaged Water Chillers

1.6 Manufacturer's Literature and Data x x

1.6 Maintenance and Operating Manuals x x

1.6 Run Test Report for All Chillers x x

1.6 Product Certificates x x

1.6 Provide Seismic Restraints for Refrigeration Equipment x x x

23 74 13 Packaged, Outdoor, Central-Station Air Handling

1.4 Manufacturer's Literature and Data x x

1.4 Maintenance and Operating Manuals x x

1.4 Written Test Procedures x x

23 81 00 Decentralized Unitary HVAC Equipment

1.4 Manufacturer's Literature and Data x x

1.4 Certification x x

1.4 Performance Rating x x

1.4 Operating and Maintenance Manual x x

23 82 00 Convection Heating and Cooling Units

1.4 Manufacturer's Literature and Data x x

1.4 Certificates x x

1.4 Operating and Maintenance Manual x x

23 82 16 Air Coils

1.4 Manufacturer's Literature and Data x x

1.4 Installation, Operating, and Maintenance Data x x

1.4 Certification Compliance x x

DIVISION 26-ELECTRICAL

26 05 11 Requirements for Electrical Installations

1.11 Manuals x x

1.11 Samples x x

26 05 13 Cables, High Voltage (Above 600 Volts)

1.3 Shop Drawings x x

ENG FORM 4288, Jul 96 01 33 00-15A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.3 Samples x x

1.3 Certifications x x

1.3 Installer Approval x x

1.3 Cable Voltage Ratings x x x

26 05 21 Low Voltage Electrical Power Conductors and Cables

1.3 Manufacturer's Literature and Data x x

1.3 Certificates x x

26 05 26 Grounding and Bonding for Electrical Systems

1.3 Shop Drawings x x

1.3 Test Reports x x

1.3 Certifications x x

26 05 33 Raceway and Boxes for Electrical Systems

1.3 Shop Drawings x x

1.3 Certification x x

26 05 36 Cable Tray Systems

1.3 Materials List x x

1.3 Manufacturer's Descriptive Literature and Sample x x

1.3 Shop Drawings x x

26 05 41 Underground Electrical Construction

1.3 Shop Drawings x x

1.3 Certificates x x

26 05 71 Electrical System Protective Device Study

1.3 Certification x x

1.3 Short-Circuit and coordination Study

1.3 Protective Device Study

26 09 26 Lighting Control Systems

1.3 System Description x x

1.3 Bill of Materials x x

1.3 Manufacturer's Data x x

1.3 Operation and Maintenance Instructions Manuals x x

ENG FORM 4288, Jul 96 01 33 00-16A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

26 12 19 Pad-Mounted Liquid Filled, Medium Voltage Transformers

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Final Up-Dated Maintenance and Operations Manual x x

1.3 Certifications x x

26 22 00 Low Voltage Transformers

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Certifications x x

26 24 11 Distribution Switchboards

1.4 Shop Drawings x x

1.4 Manuals x

1.4 Certifications x x

1.4 Manufacturer's Seismic Qualification Certification x x x

26 24 16 Panelboards

1.3 Shop Drawings x x

1.3 Certification x x

26 27 26 Wiring Devices

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Certifications x x

26 29 11 Low Voltage Motor Starters

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Updated Maintenance and Operating Manual x x

1.3 Certification x x

26 29 21 Disconnect Switches

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Certification x x

26 36 23 Automatic Transfer Switches

ENG FORM 4288, Jul 96 01 33 00-17A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.4 Shop Drawings x x

1.4 Manuals x x

1.4 Certifications x x

26 51 00 Interior Lighting

1.4 Shop Drawings x x

1.4 Samples x x

26 56 00 Exterior Lighting

1.3 Shop Drawings x x

1.3 Manuals x x

1.3 Certifications x x

DIVISION 27-COMMUNICATIONS

27 05 11 Requirements for Communications Installations

1.1 Manuals x x

1.1 Shop Drawings x x

27 10 00 Structured Cabling

1.3 Manufacturer Literature and Data x x

1.3 Certificates x x

27 11 00 Communications Equipment Room Fittings

1.5 Environmental Requirements x x x

1.5 Documents x x x

1.5 Test Equipment List x x

1.5 Samples x x

1.5 Certifications x x

1.5 Equipment Manuals x x

1.5 Record Wiring Diagram x x x

1.5 Surveys x x x x

27 15 00 Communications Horizontal Cabling

1.5 Environmental Requirements x x

1.5 Test Equipment List

1.5 Samples

1.5 Certifications

ENG FORM 4288, Jul 96 01 33 00-18A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

1.5 Equipment Manuals

1.5 Record Wiring Diagrams

DIVISION 28- ELECTRONIC SAFETY AND SECURITY

28 31 00 Fire Detection and Alarm

1.4 Drawings x x

1.4 Manuals x x

1.4 Certifications x x

DIVISION 31- EARTHWORK

31 20 11 Earth Moving (Short Form)

1.6 Rock Excavation Report x x

1.6 Soil Samples x x

32 05 23 Cement and Concrete for Exterior Improvements

1.6 Manufacturer's Certificates and Data x x

1.6 Data and Test Reports x x x

32 12 16 Asphalt Paving

1.5 Data and Test Reports x x x

1.5 Certifications x x

1.5 State Highway Department Specifications x x

1.5 Material Safety Data Sheets (MSDS) for all chemicals x x

32 14 16 Brick Unit Paving

1.3 Samples x x

1.3 Test Samples x x

32 17 23 Pavement Markings

1.2 Paint x x

1.2 Reflective Glass Beads x x x

32 31 13 Chain Link Fences

1.3 Manufacturer's Literature and Data x x

1.3 Manufacturer's Certificates x x

1.3 Shop Drawings for Chain Link Fence x x

ENG FORM 4288, Jul 96 01 33 00-19A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

32 84 00 Planting Irrigation

1.4 Manufacturer's Literature and Data x x x

1.4 Information of a permanent service organization x x x

1.4 Reproducible "as-built" drawings x x

1.4 Controllable Chart x x

32 90 00 Planting

1.4 Samples x x

1.4 Certificates of Conformance or Compliance x x

1.4 Manufacturer's Literature and Data x x

1.4 Soil Laboratory Testing Results x x x

DIVISION 33-UTILITIES

33 10 00 Water Utilities

1.5 Manufacturer's Literature and Data x x

1.5 Testing Certifications x x

33 30 00 Sanitary Sewerage Utilities

1.4 Manufacturer's Literature and Data x x x

33 40 00 Storm Drainage Utilities

1.4 Manufacturer's Literature and Data x x x

1.4 Department of Transportation Details of Manholes, Inlets, and Catch Basins x x x

33 51 00 Natural-Gas Distribution

1.5 Piping x x x x x

1.5 Pipe Coatings x x x x x

1.5 Pipe Fittings and Flanges x x x x x

1.5 Manual Valves x x x x x

1.5 Earthquake Automatic Gas Shut-off x x x x x

1.5 Valve Boxes x x x x x

1.5 Gas Filter x x x x x

1.5 Gas Pressure Regulator x x x x x

1.5 Meter x x x x

1.5 Certificates of Compliance with pressure tests on gas system x x

ENG FORM 4288, Jul 96 01 33 00-20A Submittal Register

NUMBER DESCRIPTION OF ITEM

SUBMITTED

APPROVAL

NEEDED

MATERIAL

NEEDED

TRANS-

MITTAL NO.

SUBMIT BY BY DATE DATE REMARKS

a. b. c. d. e. f. g. h. i. j. k. l. m. n. o. p. r. s. t. u. v. w. x. y. z. aa.

SUBMITTAL REGISTER CONTRACT NO.

(ER 415 1-10)

TITLE AND LOCATION CONTRACTOR SPECIFICATION SECTION

TYPE OF SUBMITTAL CLASSI-

FICATION

q.

C O D E

CONTRACTOR

SCHEDULE DATES

CONTRACTOR

ACTION

GOVERNMENT

ACTION

N O

A C T I V I T Y

S T A T E M E N T S

S C H E D U

L E S

I N S T R U C T I O N S

D R A

W I N G S

SUBMIT TO

GOVERN-

MENT

N O

I T E M C

O D E

D A T A

R E V I E W E R

A P P R O V E D

G O V E R N M E N T

I N F O R M A T I O N O N L Y

O& M

MA

N U

A L S

R E C O R D S

S A M

P L E S

C E R T I F I C A T E S

R E P O R T S

DIVISION 34- TRANSPORTATION (N/A)

ENG FORM 4288, Jul 96 01 33 00-21A Submittal Register

MATERIAL APPROVAL SUBMITTAL

(See Instructions on Reverse)

TO: (Contracting Officer) FROM: (Contractor) DATE

CONTRACT NUMBER SUBMISSION NUMBER SUBMITTAL

NEW RESUBMITTAL

PREVIOUS SUBMISSION NUMBER PROJECT NUMBER

TO BE COMPLETED BY CONTRACTOR FOR GOVERNMENT USE ONLY

ITEM

NO.

SPECIFICATION SECTION/

PARA NO./DRAWING NO.

DESCRIPTION OF MATERIAL

(Include Type, Model Number, Mfg., etc. & file name of attachments)

AP-

PROVED

DISAP-

PROVED

SEE

REVERSE INITIAL

BY COMPLETING THIS FORM, THE UNDERSIGNED CONTRACTOR CERTIFIES THAT

THE MATERIAL COMPLIES WITH ALL SPECIFICATIONS OF SUBJECT CONTRACT.

DATE TYPE OR PRINT NAME AND TITLE SIGNATURE

FOR GOVERNMENT USE ONLY

TO: (A/E)

For Evaluation and Action

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

TO: (VA Engineer / COR)

RECOMMEND APPROVAL DISAPPROVAL AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

TO: (Contracting)

APPROVED DISAPROVED AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE SIDE. REQUEST

RESUBMITTAL ON DISAPPROVED ITEMS WITHIN DAYS OF DATE SHOWN BELOW.

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

COMMENTS

(Number to correspond with applicable Item Number on reverse)

INSTRUCTIONS TO CONTRACTORS

1. The term "material" is defined as articles, supplies, raw materials, equipment, parts, components, and completed end items that are to be incorporated into the work required by the contract.

2. This form is to be used by Contractors for submitting Shop Drawings (*.DWG or *.PDF format), Manufacturer's Literature and Certificates (scanned as * .PDF) to the Government for approval in accordance with the provisions of this contract. Unless otherwise specified, it is to be prepared, signed, and E-mailed to the Contracting Officer with appropriate attachments. One paper format copy shall be submitted as well.

3. Item(s) to be approved will be clearly tabbed or identified. Data pertaining to item(s) to be approved will be clearly identified or tabbed, particularly where documents are voluminous, in order to properly evaluate the materials or articles to be incorporated in the work. Each attachment will be numbered to correspond with the item number shown on the face of this form.

4. Requests submitted shall be numbered consecutively, by contract, in the space entitled "Submission No.". This number, in addition to the Contract No., will be used to identify each Material Approval Submittal. Resubmissions will be indicated in the appropriate block and the insertion of previous submission number and data in addition to a new submission number. A single submission should be used for all work of a section of the specifications, but in NO instance should the submission include work for more than one (1) contract. Allow reasonable time in accordance with the project specifications for review of the submittal(s) by the A/E and Government. Submittals requiring priority handling will be submitted by separate submittal using the form and so marked across the face of the form.

5. This Material Approval Submittal is not valid unless it is signed by the Contracting Officer. This approval is required as called for by the Contracting Officer under the terms of this contract. One paper copy of the submittal is to be hand signed for Contracting Officers records.

6. The A/E and Government review is limited to checking for conformance with the information given and the design concept expressed in the contract documents. The Contractor and/or Construction Manager remains totally responsible for confirming all dimensions, quantities, fabrication, construction means and methods, techniques, sequences in the work, procedures, and coordination of the work for all trades.

7. This review does not relieve the Contractor of full responsibility for strict compliance with all requirements of contract plans and specifications. Provide and install all supplementary or miscellaneous items, appurtenances, devices and their available options incidental to or necessary for a functionally, sound, secure, complete, compatible and code compliant system.

Edward P. Boland VA Medical Center

VA Central Western Massachusetts Healthcare System 421 North Main Street

Leeds, MA 01053-9764

REQUEST FOR INFORMATION

NO.

PROJECT TITLE:

LOCATION: JOB:

CONTRACT NO.:

VA PROJECT NO.:

DATE REQUIRED:

TO: CC:

REQUEST SUBJECT:

Requested By: Date:

Signed:

RESPONSE:

This response does not constitute a change to the contract and is not an authorization to the contractor to proceed with any work that modifies the contract price or the time of performance. If the contractor believes that this response modifies any portion of the contract, the contractor shall make timely notice to the Contracting Officer and await the Contracting Officer’s direction before proceeding with any work that the contractor believes is a modification to the contract.

This response may constitute a change to the contract documents. Do not proceed with any work indicated in this response that changes the contract documents until directed in writing by the Contracting Officer.

Response By: Concur:

Signed:

Signed:

VA Project Manager

Date: Date:

VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance

VHA-ICRA-2023-1.0 Page 1 of 7

Introductory Information and Instructions Use this template as a baseline for performing facility Infection Control Risk Assessments (ICRAs) for construction, renovation, and maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity types and patient risk to determine the level of precautions needed to prevent infection risks. Facilities may customize this template to incorporate site-specific information and/or to add more stringent criteria.

NOTE: This VHA ICRA template pertains specifically to infection prevention. It must be used in conjunction with the required Pre-Construction Risk Assessment (PCRA) for the activity which addresses other activity-related safety concerns (e.g., vibration, noise) outside the scope of the ICRA.

To complete the template:

1. Use Table 1 to identify the category of the construction, renovation and/or maintenance activity.

2. Use Table 2 to identify the areas affected by the activity.

3. Use Table 3 to identify the overall patient risk category that will be affected by the activity.

4. Use Table 4 to determine the level of infection prevention and control precautions needed for the activity.

Once all 4 steps above are completed: Refer to Table 5 for the minimum required control measures for the level of infection prevention and control precautions needed for the activity. Refer to Table 6 for the minimum infection prevention and control measures required on completion of the activity.

PERMIT: See the last page of this document for a fillable permit form to be used for posting at the activity site as needed.

Table 1 - Construction, Renovation, and/or Maintenance Activity Category

NOTE: If any of the bulleted criteria in a higher activity category pertains to the work that will be done (even if the other criteria are in a lower category), use the higher activity category for the VHA ICRA.

Activity Category determined from Table 1 (A, B, C, or D):

Category A

Inspection and/or facility upkeep generally defined as follows:

• Work can be completed in a single shift, not to exceed 10 hours.

• Patients and/or employees may be in the area depending on the activity.

• Work that does not create dust or debris.

• Removal of ceiling tile or access to mechanical or electrical chase for visual inspection limited to 1 tile per 50 square feet with limited exposure time (not to exceed an hour for each tile) within the shift.

• Minor interior updates (e.g., replacing floor or ceiling tiles, carpentry work to include hanging signage, and painting without sanding) that do not create dust or debris.

• Limited building system maintenance such as plumbing on potable systems limited to faucet replacement etc. and electrical work such as replacement of bulbs, receptacles, or switches.

B

General maintenance and repair work generally defined as follows:

• Prolonged inspection and work that may take longer than a single shift but not exceeding a week.

• Patients and employees are not to be in the area until activity is completed.

• Work that creates minimal dust and debris.

VHA-ICRA-2023-1.0 Page 2 of 7

• Interior finish or surface repairs, updates, or modifications such as repair of firewalls and barriers, and new flooring that produces minimal dust and debris. Controlled sanding activities (e.g., wet or dry sanding) that produce minimal dust and debris.

• Plumbing work such as installation or replacement of a single fixture or piping for a single fixture. Any work on sanitary plumbing including snaking of drains.

• Electrical work such as installation of cabling/wiring/conduit for a single device, installation of new device such as a light fixture that produces minimal dust and debris.

• Air Handler and/or fan shutdown/startup and HVAC work such as replacement of a single diffuser, single terminal unit or a single device that produces minimal dust and debris.

C

Small-scale construction, renovation, or maintenance generally defined as follows:

• Work requiring longer than a single week to complete but not exceeding 6 months.

• Patients and employees are not to be in the area until activity is completed.

• Demolition/removal of preexisting floor covering, casework, lay-in ceiling, or other architectural elements.

• Demolition/removal of more than 32 ft2 of drywall/framing, hard ceilings, and doors/framing and minimal infrastructure such as electrical circuits and branch piping.

• Installation of new walls, ceilings and doors including framing, drywall/plaster and associated work.

• Plumbing work such as the installation of new sinks, showers and toilets and associated plumbing.

• Shut down of sections of potable water systems.

• Electrical work such as installation of conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc.

• Modification of existing fire alarm and suppression systems.

• Mechanical work such as the installation of ductwork, diffusers, and terminal units for an area.

D

Large-scale construction, renovation, or maintenance generally defined as follows:

• Work exceeding 6 months in duration.

• Patients and employees are not to be in the area until activity is completed.

• Large-scale demolition of building components and infrastructure including removal of multiple doors, walls, framing, ceilings, flooring, piping, electrical and HVAC.

• The installation building components such as new walls, ceilings and doors including framing, drywall and associated plaster work.

• Plumbing work such as the installation of:

o new medical gas systems, o steam/heating hot water, condensate systems, o multiple sinks, showers and toilets including associated plumbing.

• Shutdown of potable water, steam/heating hot water, condensate, and medical gas systems.

• Electrical work such as installation of electrical feeders, distribution panels, conduit and wire for lighting, receptacles and switches for an area, the installation of conduit and wire for new devices such as terminal units, fans etc.

• Installation of fire alarm and suppression systems.

• Electrical shutdown of multiple panels.

• Mechanical work such as the installation of air handling equipment, associated ductwork, diffusers, heat exchangers, terminal units and controls.

VHA-ICRA-2023-1.0 Page 3 of 7

Table 2 - Affected Area Assessment

Identify the areas and associated patients that will be affected by the construction/renovation/maintenance activity (see the Figure for a visual representation of adjacent affected areas).

Figure: Isometric drawing of affected area assessment

Area Service(s)/Type(s) of Area(s) (e.g., OR, Unit/Ward, Sterile

Processing, Administrative, etc.)*

Point of Contact (POC) POC Contact Information

Activity Area**

Area Above

Area Below

Adjacent Area 1

Adjacent Area 2

Adjacent Area 3

Adjacent Area 4

* There may be more than one Service/type of area for each row. List all.

** List the area(s) in which the construction/renovation/maintenance activity will occur. NOTE: When the Activity Category is B, C, or D, the control measures are determined by the Patient Risk in the adjacent affected areas.

VHA-ICRA-2023-1.0 Page 4 of 7

Table 3 - Patient Risk Category

Using Table 3, identify the patient risk category for each area listed in Table 2. Of the patient risk categories identified, select the one with the greatest risk as the overall Patient Risk Category for the activity.

Overall Patient Risk Category determined from Table 3 (Low, Medium, High, or Highest):

Low Risk

Non-patient care areas such as:

Medium Risk

Patient care support areas such as:

High Risk

Patient care areas such as:

Highest Risk

Procedural, invasive, sterile support and highly compromised patient care areas such as:

• Public hallways and gathering areas not in clinical areas

• Office areas not in clinical areas

• Breakrooms not in clinical areas

• Bathrooms or locker rooms not in clinical areas

• Mechanical/electrical rooms not in clinical areas

• Waiting areas

• Clinical engineering (biomedical)

• Materials management

• Sterile processing department – dirty side

• Kitchen, cafeteria, gift shop, coffee shop, and food kiosks

• Patient care rooms and areas, including spinal cord injury units

• All acute care units, including mental health

• All outpatient units and clinics

• Emergency department

• Community Living Centers, domiciliaries, and transitional residences

• Employee health

• Pharmacy – general work zone

• Medication rooms and clean utility rooms

• Imaging suites – diagnostic imaging

• Laboratory

• All transplant units

• All intensive care units

• All oncology units and chemotherapy/infusion centers

• OR theaters and restricted areas

• Hemodialysis units

• Procedural rooms*

• Pharmacy compounding area

• Sterile processing department – clean side

• Transfusion services

• Imaging suites – interventional imaging

• Dedicated isolation wards/units for infectious diseases

* Procedural Rooms are designated for the performance of patient care activities that may require high-level disinfected or sterile instruments and some environmental controls but is not required to be performed with the environmental controls of an operating room (OR). The room is intended for procedures that are performed in an aseptic surgical field and penetrates the protective surfaces of a patient’s body (e.g., subcutaneous tissue, mucous membranes, cornea) or entry into or opening of a sterile body cavity. Examples of these spaces include Cardiac Catheterization Suites, Electrophysiology Suites, Endovascular/GI Suites, Angio Suites and other spaces which may have high risk patient populations.

VHA-ICRA-2023-1.0 Page 5 of 7

Table 4 - Level of Infection Prevention and Control Precautions

Match the Overall Patient Risk Category (Low, Medium, High, Highest) determined from Table 3 with the planned Construction/Renovation/Maintenance Activity Category (A, B, C, D) from Table 1 to determine the minimum Level of Infection Prevention and Control Precautions (I, II, III, or IV) using Table 4 below.

Level of Precautions determined from Table 4 (I, II, III, or IV):

An infection…