Download request for inspection of material

REQUEST FOR INSPECTION OF PLANT MATERIAL
CDOT Project No:
Date:
Resident Engineer to assign T-Number and retain
records in job file. RE must send one completed
copy to CDOT Quality Assurance (QA) 30 N.
LaSalle, Suite 400 Chicago, IL 60602 for
processing.
CITY HORTICULTURIST CONTACT INFORMATION
ELEANORE SKOPEK
CELL:
(312) 735-1637
OFFICE: (312) 743-1393
FAX:
(312) 743-1394
MUST BE COMPLETED
Project Description:
IDOT Contract No:
Resident Engineer:
Resident Engineer Cell:
Project Completion Date:
Contractor:
Address:
Tel / Fax:
Subcontractor:
Address:
COMPLETED BY
ENGINEER / CITY
MUST BE COMPLETED
Tel / Fax:
EMAIL:
[email protected]
EMAIL:
PAY
GENUS SPECIES CULTIVAR
ITEM NO.
(ITEM DESCRIPTION)
UNIT SIZE
QTY
UNIT
NURSERY CERTIFICATION (Only one Nursery per Inspection Report). Nurseries must hold a current nursery
certificate issued by the residing state.
I hereby certify that the items listed above to be used in
NURSERY:
construction of the subject project comply with all
contract requirements.
NURSERY CODE:
ADDRESS:
Certified by
Nursery
Representative:
TELEPHONE:
Name:
FAX:
Title:
CITY ENDORSEMENT
The above material was inspected on (Date):
Accepted By:
(City Horticulturist)
Approved by:
(Resident Engineer)
This RFIPM has been reviewed by CDOT QA and has been found to be Acceptable.
Reviewer:
cc: Contractor
Resident Engineer
CDOT QA
CDOT Division of Engineering – Eleanore Skopek
Inspection
TReport
Page
No.:
of
Date:
Revised 04/12
Resident Engineer to assign T-Number and retain
records in job file. RE must send one completed
copy to CDOT Quality Assurance (QA) 30 N.
LaSalle, Suite 400 Chicago, IL 60602 for
processing.
CITY HORTICULTURIST CONTACT INFORMATION
ELEANORE SKOPEK
CELL:
(312) 735-1637
OFFICE: (312) 743-1393
FAX:
(312) 743-1394
MUST BE COMPLETED
REQUEST FOR INSPECTION OF PLANT MATERIAL
CDOT Project No:
1
Project Description:
3
IDOT Contract No:
4
Resident Engineer: 5
Resident Engineer Cell:
Project Completion Date:
Contractor:
8
Address:
9
Tel / Fax:
Subcontractor:
Address:
Tel / Fax:
EMAIL:
[email protected]
EMAIL:
PAY
GENUS SPECIES CULTIVAR
ITEM NO.
(ITEM DESCRIPTION)
MUST BE COMPLETED
15
2
6
7
10
11
12
13
14
16
UNIT SIZE
QTY
UNIT
17
18
19
NURSERY CERTIFICATION (Only one Nursery per Inspection Report). Nurseries must hold a current nursery
certificate issued by the residing state.
I hereby certify that the items listed above to be used in
NURSERY:
20
construction of the subject project comply with all
contract requirements.
NURSERY CODE:
21
ADDRESS:
COMPLETED BY
ENGINEER / CITY
Date:
Certified by
Nursery
Representative:
22
TELEPHONE:
23
Name:
26
FAX:
24
Title:
27
25
CITY ENDORSEMENT
The above material was inspected on (Date):
Accepted By:
29
(City Horticulturist)
Approved by:
(Resident Engineer)
28
30
This RFIPM has been reviewed by CDOT QA and has been found to be Acceptable.
Reviewer:
32
cc: Contractor
Resident Engineer
CDOT QA
CDOT Division of Engineering – Eleanore Skopek
Date:
Inspection
T- 31
Report
Page 34 of
No.:
33
Revised 04/12
INSTRUCTION FOR THE REQUEST FOR INSPECTION OF PLANT MATERIAL
This form must be completed by the Contractor and Nursery Representative, and is to be submitted by the Contractor in
triplicate to the CCE. The submittal is required in a timely manner, allowing adequate time for review by the CCE and a
minimum seven week lead time for the City of Chicago Horticulturist to review and inspect the plant material at the
nursery prior to delivery.
ITEM
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
GENERAL INSTRUCTIONS
City of Chicago Project Number
Date that the Request for Inspection of Plant Material is generated
Project Description
IDOT Contract Number (if applicable)
Consultant Resident Engineer or City of Chicago Resident Engineer (if there isn’t a Consultant Resident
Engineer for the Project).
Resident Engineer Cell Phone Number
Project Completion Date
Project General Contractor
Project General Contractor Address
Project General Contractor Telephone and Fax Numbers
Subcontractor performing the work (if applicable)
Subcontractor Address (if applicable)
Subcontractor Telephone and Fax Numbers (if applicable)
Subcontractor e-mail address (if applicable)
Contract Pay Item Number (example: 300)
Pay Item Description (example: Sedum “Dragons Blood” – Dragons Blood)
Unit Size (example: 5 Gallon, 12 Flat, 4” Pot, etc.)
Quantity (example: 2,000)
Unit of Measure (example: Each)
NURSERY CERTIFICATION – This section must be completed by the nursery prior to the contractor
submitting the RFIPM form to the CCE for review.
20.
21.
22.
23.
24.
25.
26.
27.
The Nursery Supplying the Plant Material
The Nursery’s Code which verifies that the Nursery is certified in their residing state.
The Nursery’s Address, including street, city and state
The Nursery’s Telephone Number
The Nursery’s Fax Number
Signature of Nursery Representative
Nursery Representative’s Printed Name
Nursery Representative’s Title
CITY ENDORSEMENT – Prior to delivery, a City of Chicago Horticulturist must inspect and accept the plant
material at the nursery; then sign and date the RFIPM form. After acceptance by the City of Chicago
Horticulturist is complete, the CCE must assign a T-number to the RFIPM form and sign it. The CCE shall
retain one copy for the project files and forward two copies to CDOT QA with a CDOT Material Inspection
Transmittal Letter attached.
28.
29.
30.
31.
The Date of Inspection by the City of Chicago Horticulturist
Signature of the City of Chicago Horticulturist
Signature of the Resident Engineer
RE to assign T-number in sequential order
CDOT QA ENDORSEMENT – This section is completed by CDOT QA after a thorough review of the RFIPM
submittal has been completed. If the documentation is in order and meets the project documentation
requirements, a CDOT QA representative will sign and dates the RFIPM form and return to the CCE a copy of
the CDOT Materials Inspection Transmittal Letter indicating CDOT QA’s disposition. All incomplete or
incorrect submittals will be returned to the CCE for revision and resubmittal.
32.
33.
34.
Signature of authorized CDOT QA representative.
The date the RFIPM form was signed by the CDOT QA representative
If creating multiple pages under a single “T” number fill in each page number sequentially and indicate the
total number of RFIPM pages utilized in the submittal. For single paged RFIPM submittals always indicate
Page 1 of 1.