Contractor:

Contractor's Architect:

Address:

Address:

Phone:

Phone:

Contract Title:

Contract Number:

RFI Number:

Date of Request:

Date Response Required

(7 days minimum):

Description of RFI:

As Built Sketches Enclosed:

Specification Paragraph Ref:

Drawing Reference:

Contractor's Recommendation:

Cost Impact:

Schedule Impact:

Subcontractors Affected:

Subcontractors Coordinated With:

Submitted by:

Architect/Engineer’s Response:

Response by:

Date:

                                    PART I - STATEMENT OF PRIME CONTRACTOR

1. PRIME CONTRACT #:

2. CONTRACT TITLE:

3. SUBCONTRACTOR #:

4. DATE SUBCONTRACT AWARDED:

4. PRIME CONTRACTOR (Name, Address, Phone)

5. SUBCONTRACTOR (Name, Address, and Phone)

6.The Prime Contractor states that under the Contract shown in Item 1, a subcontract was awarded on the date shown in Item 4 by (name of awarding firm):                                                                                                                                                    

to the subcontractor in Item 5 for the following work:

7.                                                                                         

     Name and Title

8.                                                  

    Signature

9.                                              

   Date

                             PART II - ACKNOWLEDGEMENT OF SUBCONTRACTOR

10.The subcontractor acknowledges that, as a minimum, the following clauses of the Contract shown in item 1 are included in the subcontract:

GENERALSPECIALFEDERAL-AID CONTRACTOR AFFIRMITIVE

PROVISIONSPROVISIONSPROVISIONSACTION PROGRAM

GP-2.05SP-1.06FAA-1.04AAP-1.01

GP-7.01SP-6.03FAA-1.05AAP-2.02

GP-7.02SP-6.04FAA-1.06

GP-7.05SP-6.05FAA-1.07

GP-7.13SP-6.06FAA-2.06

GP-7.14SP-8:01FAA-2.12

GP-7.20SP-8.07FAA-4.02

GP-7.23SP-9.01FAA-4.03

GP-7.30FAA-4.05

GP-7.36

GP-8.01

GP-9.01

11. NAMES(S) OF ANY HIGHER, OR LOWER TIER SUBCONTRACTORS, IF ANY:

12.                                                                                     

      Name and Title

13.                                               

     Signature

14.                                             

     Date

Contract Title:

Page _______ of _______

Contract Number:

Date:

Contractor Name:

Invoice Number:

MBE Utilization To-Date (%):

MBE Goal (%):

                                           GENERAL CONTRACTOR STATEMENT

    Payment Through Last Period

          Payment This Period

        Total Payment To-Date

                                        MBE SUBCONTRACTOR PARTICIPATION

   Payment Through Last Period

         Payment This Period

       Total Payment To-Date

MBE Subcontractor Number 1 (Name):

MBE Subcontractor Number 2 (Name):

MBE Subcontractor Number 3 (Name):

MBE Subcontractor Number 4 (Name):

MBE Subcontractor Number 5 (Name):

MBE Subcontractor Number 6 (Name):

MBE Subcontractor Number 7 (Name):

                 MONTHLY INJURY/ILLNESS REPORT

                       (TO BE COMPLETED AND MAILED BY THE 7TH DAY OF EACH MONTH)

FOR THE MONTH OF: ________________________________________________     

PROJECT NUMBER:                           PROJECT NAME: ___________________                                          

PROJECT LOCATION: ________________________________________________                                                               

CONTRACTOR OR SUBCONTRACTOR

NAME: _____________________________________________________________

ADDRESS:__________________________________________________________

TELEPHONE NO.:                                                                             FAX NO.:

1.  HOURS WORKED

    2.  LOST TIME CASES

    3.  RECORDABLE CASES

    4.  LOST WORK DAYS

    5.  CARRY OVER LOST WORK DAYS

    6.  TOTAL LOST WORK DAYS

COMMENTS:

PREPARED BY:                                                                                DATE:

MARYLAND AVIATION ADMINISTRATION

CONTRACT NO. MAA-C0-00-000

BASE BID SCHEDULE OF VALUES

Division

Item

General Contractor

Subcontractors

Total Costs

Labor

Materials

Labor

Materials

Division 02

Site Work

Division 03

Concrete

Division 04

Masonry

Division 05

Metals

Division 06

Carpentry

Division 07

Moisture Protection

Division 08

Doors, Windows, Glass

Division 09

Finishes

Division 10

Miscellaneous Specialties

Division 11

Equipment

Division 12

Furnishings

Division 13

Special Construction

Division 14

Conveying Systems

Division 15

Mechanical

Division 16

Electrical

Subtotal

GC General Conditions

GC Overhead & Profit

CQC Plan (Min. 3% of Subtotal)

GC Mobilize / De-Mobilize

GC Bonds

GC Insurance

Miscellaneous Allowance

Totals

I.      GENERAL INFORMATION

Date

Contractor Company Name

Contract/Building Permit No.

Contract/Building Permit Title

Description of circuit/equipment

Description of proposed work

II.    TO BE COMPLETED BY CONTRACTOR

1)    Date and Time of Proposed Work

2)    Location of Proposed Work (Attach exhibit of Floor Plan)

3)    Detailed description of proposed work to be done including description of procedure to be used in performing work

4)    Justification of why the circuit/equipment cannot be de-energized for the proposed work

5)    Description of the safe work practices to be employed

6)    Shock Risk Assessment

a)    Voltage to which personnel will be exposed: 

b)    Limited approach boundary: 

c)     Restricted approach boundary: 

d)    Necessary shock, personal, and other protective equipment to safely perform work: 

7)    Arc Flash Risk Assessment

a)    Available incident energy at the working distance or arc flash PPE category: 

b)    Necessary arc flash personal and other protective equipment to safely perform work (If Arc flash label/ incident energy level label is not present, the contractor must take all necessary precautions for safety in accordance with the current applicable codes and standards): 

c)     Arc flash boundary: 

8)    Means employed to restrict the access of unqualified persons from work area

9)    Name of Electrically Qualified Person performing proposed work

II.a. CONTRACTOR SIGNATURE

Requestor’s Name and Title (Printed)

Requestor’s Signature                                                                           Date

I have reviewed and agree that the above described work can be done safely.

Safety Manager Signature                                                                      Date

I.              APPROVAL BY CMI REPRESENTATIVE

Engineer’s Name and Company (Printed)

Engineer’s Signature                                                                          Date

I.              APPROVAL (FOR MAA USE ONLY)

MAA Office of Facilities Maintenance Approver Name (Printed)

MAA Office of Facilities Maintenance Approver Signature                Date