HomeMy WebLinkAbout98-58 Resolution No. 98-58
RESOLUTION
AUTHORIZING EXECUTION OF A CONSTRUCTION ENGINEERING
SERVICES AGREEMENT WITH BRW, INC.
BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF ELGIN,
ILLINOIS, that Joyce A. Parker, City Manager, and Dolonna
Mecum, City Clerk, be and are hereby authorized and directed to
execute a Construction Engineering Services Agreement on behalf
of the City of Elgin with BRW, Inc . for the CMAQ U. S. 20 Bike
Path Project, a copy of which is attached hereto and made a
part hereof by reference.
s/ Kevin Kelly
Kevin Kelly, Mayor
Presented: March 11, 1998
Adopted: March 11, 1998
Omnibus Vote: Yeas 7 Nays 0
Attest :
s/ Dolonna Mecum
Dolonna Mecum, City Clerk
III
City of Elgin
•
�� q Agenda Item No.
February 6 , 1998
TO: Mayor and Members of the City Council
FROM: Joyce A. Parker, City Manager
SUBJECT: BWR (Dames and Moore) CMAQ US 20 Bike Path
Project - Construction Engineering Contract
PURPOSE
The purpose of the memorandum is to provide the Mayor and
members of the City Council with information to consider
entering into an agreement with BWR (Dames and Moore) for
construction engineering services of the CMAQ (Congestion,
Mitigation and Air Quality Program) US 20 Bike Path project .
BACKGROUND
SThe City of Elgin entered into an Engineering Services Agree-
ment with BRW (Dames and Moore) on September 12 , 1997 and
reassignment on February 11, 1998 for the design and prepara-
tion of the construction documents for the US 20 Bike Path
Project . The Construction Engineering Services agreement as
required by the Illinois Department of Transportation (IDOT)
and the CMAQ Grant is attached.
IDOT has recommended to proceed with the construction engi-
neering/construction management phase of this project with BRW
(Dames and Moore) . BRW has prepared the construction drawings
for the US Route 20 Bike Path Project and, therefore, are
familiar with the project .
The Construction Engineering services will be for on-site
construction management of the project by an IDOT approved
engineer. Construction will be scheduled by IDOT for late
summer, with completion by December 1, 1998 .
COMMUNITY GROUPS/INTERESTED PERSONS CONTACTED
None .
•
BRW (Dames and Moore) Project
February 6 , 1998
Page 2
FINANCIAL IMPACT
The CMAQ Grant is an 80/20 matching funds program for the
design and construction of the bike path. The project totals
$201, 940 for design and construction of the bike path. Dames
and Moore ' s fee for construction engineering services will be
$18 , 350 . The Federal match equals $161, 552, with the City' s
match totalling $40, 388 . Eighty percent of the construction
engineering services will be reimbursed by the CMAQ Program.
Sufficient funds are budgeted and available within account
number 385-0000-795 . 92-32 , Land Improvements, project number
509543 , CMAQ Bike Path Construction.
LEGAL IMPACT
V �1 None . -
ALTERNATIVES
None .
RECOMMENDATION
It is recommended that the City Council approve the attached
Amendment No. 1 (Construction Engineering Service Agreement)
with BRW in the amount of $18 , 350 .
Respectfully submitted,
Miter.42-,
Monica Meyers
Director of Parks and
'ecreation
41111
Ali
• ce ��. Parker
City Manager
jP
Illinois Department of Transportation
2300 South Dirksen Parkway! Springfield, Illinois /62764
June 1, 1998
City of Elgin
Section 97-00160-00-BT
Project No. CMM-7003(491)
Job No. C-91-261-97
Construction Engineering Agreement
Dolonna Mecum
City Clerk
150 Dexter Ct.
Elgin, IL 60120
Dear Ms. Mecum:
The agreement for construction engineering services, with BRW, Inc. in the
amount of$18,350.00 (federal share, $14,680.00), was approved by the
department effective June 1, 1998.
The city may authorize the consultant to proceed with the engineering work
called for in the agreement.
Your file copy of the approved engineering agreement is attached. If you have
any questions contact Dan Atteberry, (217)785-1675.
Sincerely,
Darrell W. McMurray, P. E.
Engineer of Local Roads and Streets
cc-
Joseph Evers, Municipal Engineer
BRW, Inc.
John P. Kos Attn: Nancy Magnus
David G. Campbell Attn: Clarence Crowder
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Municipality Name
City of Elgin L BRW, INC.
O Illinois Department c
County c of Transportation o Address
Kane A N 1701 Golf Road, Suite 1000
L S
Township City
Construction Engineering U Rolling Meadows
A Services Agreement L
Section G For T State
97-00160-00-BT E Federal Participation A Illinois
N N
Project No. C (Type of Funding) T Zip Code
CMM-7003(491) Y STA 60008
Job No. Existing Structure No: NA
C-91-261-97 Proposed Structure No.: NA
THIS AGREEMENT is made and entered into this day of , 19 98 between the above Local Agency (LA) and
Consultant(ENGINEER)and covers certain professional engineering services in connection with the construction of the above
SECTION. Federal-aid Funds allotted to the LA by the State of Illinois under the general supervision of the State Department
of Transportation,hereinafter called the"STATE",will be used entirely or in part to finance ENGINEERING services as described
under AGREEMENT PROVISIONS.
WHEREVER IN THIS AGREEMENT the following terms are used,they shall be interpreted to mean:
District Engineer District Engineer, Department of Transportation
Resident Engineer LA employee directly responsible for construction of SECTION
Contractor Company or Companies to which the construction contract was awarded
Project Description
Name U.S. Route 20 Bike Path Route Length 2.61 Km.
Termini Elgin Community College through Elgin Sports Complex
Description: Construction of bituminous bikepath along with required drainage,striping, signage and all incidental work.
Agreement Provisions
The Engineer Agrees,
1. To perform or be responsible for the performance of the following engineering services for the LA, in connection with the
proposed improvement hereinbefore described, and checked below:
a.(x) Proportioning and testing of concrete mixtures in accordance with the "Manual of Instructions for Concrete
Proportioning and Testing"issued by the Bureau of Materials and Physical Research, of the STATE and promptly
submit reports on forms prepared by said Bureau.
b.(x) Proportioning and testing of bituminous mixtures (including extraction test) in accordance with the "Manual of
Instructions for Bituminous Proportioning and Testing"issued by the Bureau of Materials and Physical Research,
of the STATE, and promptly submit reports prepared by said Bureau.
c.(x) All compaction tests as required by the specifications and report promptly the same on forms prepared by the
Bureau of Materials and Physical Research.
d.(x) Quality and sieve analyses on local aggregates to see that they comply with the specifications contained in the
contract.
e.(x) Inspection of all materials when inspection is not provided at the sources by the Bureau of Materials and Physical
Research,of the STATE, and submit inspection reports to the LA and the STATE in accordance with the policies
of the said STATE.
BLR 4352(Rev. 11/89)
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f.(x) Inspect,document,and inform the resident engineer of the adequacy of the establishment and maintenance of the
traffic control.
g.(x) Geometric control including all construction staking and layouts.
h.(x) Quality control in the construction work in progress and the enforcement of the contract provisions in accordance
with the STATE Construction Manual.
I.(x) Measurement and computation of pay items.
j.(x) Maintain a daily record of the contractor's activities throughout construction including sufficient information to permit
verification of the nature and cost of changes in plans and authorized extra work.
k.(x) Preparation and submission to the LA in the required form and number of copies, all partial and final payment
estimates, change orders, records, documentation, and reports required by the LA and the STATE.
I.(x) Revision of contract drawings to reflect as built conditions.
2. Engineering services shall include all equipment, instruments,supplies,transportation and personnel required to perform
the duties of the ENGINEER in connection with the AGREEMENT.
3. To furnish the services as required herein within twenty-four hours of notification by the RESIDENT ENGINEER or
authorized representative.
4. To attend conferences and visit the site of the work at any reasonable time when requested to do so by the LA or
representatives of the STATE.
5. That none of the services to be furnished by the ENGINEER shall be sublet, assigned, or transferred to any other party
or parties without the written consent of the LA. The consent to sublet, assign or otherwise transfer any portion of the
services to be furnished by the ENGINEER shall not be construed to relieve the ENGINEER of any responsibility for the
fulfillment of this AGREEMENT.
6. That payment by the LA shall be as hereinafter provided. The ENGINEER shall submit invoices, based on his progress
reports,to the RESIDENT ENGINEER,no more than once a month for partial payment on account for his work completed
to date. Such invoices shall represent the value,to the LA of the partially completed work, based on the sum of the actual
costs incurred, plus a percentage(equal to the percentage of the construction engineering completed) of the fixed fee for
the fully completed work.
7. That the engineer is qualified technically and is entirely conversant with the design standards and policies applicable to
improvement of the SECTION; and that he has sufficient properly trained, organized and experienced personnel to
perform the services enumerated herein.
8. That the ENGINEER shall be responsible for the accuracy of the ENGINEER'S work and correction of any errors,
omissions or ambiguities due to the ENGINEER'S negligence which may occur either during prosecution or after
acceptance by the LA. Should any damage to persons or property result from his error, omission or negligent act,the
ENGINEER shall indemnify the LA and its employees form all accrued claims or liability and assume all restitution and
repair costs arising from such negligence. He shall give immediate attention to any remedial changes so there will be
minimal delay to the contractor and prepare such data as necessary to effectuate corrections, in consultation with and
without further compensation from the LA.
9. That the ENGINEER will comply with applicable Federal Statutes, State of Illinois Statutes, and local laws or ordinances
of the LA.
BLR 4352(Rev.11/89)
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The Engineer Further Agrees,
to comply with all applicable Equal Employment and Nondiscrimination Acts, Executive Orders, and Regulations required by
the U.S. Department of Transportation (DOT) including:
a. 23 USC 710.405(b), Nondiscrimination on Basis of Sex in Right-of-Way Acquisition.
b. 42 USC 2000d-1, Title VI of the Civil Rights Act of 1964 (Nondiscrimination on Basis of Race, Color, or National
Origin).
c. 49 CFR 21, Nondiscrimination in DOT Programs.
d. 49 CFR 23, participation by MBE's in DOT Programs.
It is the policy of the U.S. Department of Transportation that Minority Business Enterprises, as defined in 49 CFR
Part 23,shall have the maximum opportunity to participate in the performance of contracts/agreements financed
in whole or in part with Federal funds under this AGREEMENT.
The ENGINEER agrees to ensure that minority business enterprises, as defined in 49 CFR Part 23, have the
maximum opportunity to participate in the performance of this AGREEMENT. In this regard,the ENGINEER shall
take all necessary and reasonable steps in accordance wit 49 CFR Part 23, to ensure that minority business
enterprises have the maximum opportunity to compete for and perform portions of this AGREEMENT. The
ENGINEER shall not discriminate on the basis of race, color, national origin, or sex in the selection and retention
of subcontractors, including procurement of materials and leases of equipment.
The ENGINEER shall include the provisions of this"Policy"in every subcontract, including procurement of materials
and leases of equipment.
Failure to carry out the requirements set forth above shall constitute a breach of this AGREEMENT and may result
in termination of the AGREEMENT or such remedy as deemed appropriate.
e. 49 CFR 27, Nondiscrimination on Basis of Handicap.
The LA Agrees,
1. To furnish a RESIDENT ENGINEER to be in responsible charge of general supervision of the construction.
2. To furnish the necessary plans and specifications.
3. To notify the ENGINEER at least twenty four hours in advance of the need for personnel or services.
4. That for the performance by the ENGINEER of the services set forth above, the LA shall pay the ENGINEER on the
following basis of payment:
Amount of Basic Fee. The ENGINEER shall receive, as full payment for completing all work required of him under this
AGREEMENT, a basic fee, consisting of payment for the items shown in Section 4(a), (b), (c) and (d) hereof.
a. The ENGINEER shall be reimbursed for his actual costs related to the salaries of his employees for the time
directly attributable and properly chargeable to the SECTION under the terms of this AGREEMENT, including
salaries of principals of the ENGINEER for time they are productively engaged in work necessary to fulfill the terms
of this AGREEMENT. A tabulation showing the present regular hourly salary range for each class of employee
expected to work on this SECTION is as follows:
Hourly Rate Range
Classification From To
Principal Engineer $34.00 $55.00
Project Manager 20.00 37.00
Resident Engineer 19.00 32.00
Construction Engineer 13.00 21.00
Construction Technician 8.00 26.00
Clerical 9.00 15.00
Drafter 12.00 18.00
BLR 4352(Rev. 11/89)
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The classifications of the employees used in the work should be consistent with the employee classifications and
estimated manhours shown in EXHIBIT A. If the personnel of the firm, including the Principal Engineer, perform
routine services that should normally be performed by lesser-salaried personnel, the wage rate billed for such
services shall be commensurate with the work performed.
In the event that additional classes of employees must be utilized or if salary adjustments are made,the above data
may be modified by agreement between the ENGINEER and the LA.
Costs related to salaries shall include actual withholdings and contributions by either the employee or the
ENGINEER for the approved payroll burden items set forth in Exhibit A of this AGREEMENT.
b. The ENGINEER shall be reimbursed for his direct non-salary costs which are directly attributable and properly
allocable to the Project.
(1) Direct non-salary costs paid by the ENGINEER may also include in-plant and travel expenses. Travel
expenses within the State of Illinois only,that are necessary to fulfill the terms of this AGREEMENT, may be
directly charged to the SECTION. Reimbursable travel expenses shall include the reasonable cost of meals,
lodging,incidental expenses,and transportation for regular employees and principals of the ENGINEER only
while away from their regular place of duty and directly engaged on the SECTION. Travel expenses may
be based on actual costs, or on an agreed per diem or mileage basis, or on a combination of the two,
provided the resulting charge is reasonable. The ENGINEER will not be required to submit receipts for
reimbursement of in-plant and travel expenses, but will be required to submit a detailed listing of such actual
expenses certified by him to be direct SECTION costs that are not included in overhead.
(2) The withholding provisions contained in Section 5a and 5b of this AGREEMENT shall not apply to costs
enumerated in Section 4b above.
c. The ENGINEER shall be reimbursed for his actual overhead or indirect costs to the extent that they are property
allocable to the SECTION. Such costs shall be established in accordance with sound accounting principles and
business practices. Such costs are included in the overhead and expense rate set forth in EXHIBIT A of this
AGREEMENT. The rate shown in EXHIBIT A is provisional for use in computing partial payments. Upon
completion of the SECTION, final payment for indirect costs will be determined by audit of the ENGINEER'S
accounts to establish the actual indirect costs incurred during the period of this AGREEMENT which are properly
allocable to it.
d. The ENGINEER shall be paid fixed fee(lump sum) of$1,846.00 to cover profit only. The maximum total amount
payable, including actual costs, fixed fee, and contingencies, shall not exceed $18,350.00 unless there is a
substantial change in the scope,complexity, or character of the work, or there is a substantial overrun in the time
necessary for the ENGINEER to complete the work due to causes beyond his control. Under these
circumstances, adjustments in total compensation to the ENGINEER shall be determined through negotiation
between the parties of this AGREEMENT and concurred in by the STATE.
5. Partial Payments. The LA, for and in consideration of the rendering of the engineering services enumerated herein,
agrees to pay to the ENGINEER for rendering such services the basic fee hereinafter established in the following manner:
a. For the first 50% of completed work, and upon receipt of monthly invoices from the ENGINEER and the
approval thereof by the LA, monthly payments for the work performed shall be due and payable to the
ENGINEER,such payments to be equal to 90% of the value of the partially completed work(See Section 6 of THE
ENGINEER AGREES) minus all previous partial payments made to the ENGINEER.
b. After 50%of the work is completed,and upon receipt of monthly invoices from the ENGINEER and the approval
thereof by the LA,monthly payments covering work performed shall be due and payable to the ENGINEER, such
payments to be equal to 95% of the value of the partially completed work (See Section 6 of THE ENGINEER
AGREES) minus all previous partial payments made to the ENGINEER.
c. Final Payment - Upon approval by the LA but not later than 60 days after the work is completed and all final
measurements and reports have been made and accepted by the LA, a sum of money equal to the basic fee as
determined in this AGREEMENT less the total of the amounts of partial payments previously paid to the
ENGINEER under Section 5a and 5b of this AGREEMENT shall be due and payable to the ENGINEER.
BLR 4352(Rev. 11/89)
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It is Mutually Agreed
1. That the ENGINEER and his subcontractors will maintain all books, documents, papers, accounting records and other
evidence pertaining to cost incurred and to make such materials available at their respective offices at all reasonable times
• during the AGREEMENT period and for three years from the date of final payment under this AGREEMENT,for inspection
,by the STATE, Federal Highway Administration, or any authorized representatives of the Federal Government and copies
thereof shall be furnished if requested.
2. That all services are to be furnished as required by construction progress and as determined by the RESIDENT ENGINEER.
The ENGINEER shall complete all services specified herein within a time considered reasonable to the LA, after the
CONTRACTOR has completed the construction contract.
3. That all field notes,test records and reports shall be turned over to and become the property of the LA and that during the
performance of the engineering services herein provided for, the ENGINEER shall be responsible for any loss or damage
to the documents herein enumerated while they are in his possession and any such loss or damage shall be restored at his
expense.
4. That this AGREEMENT may be terminated by the LA upon written notice to the ENGINEER, at his last known post office
address,with the understanding that should the AGREEMENT be terminated by the LA,the ENGINEER shall be paid for
any services completed and any services partially completed. The percentage of the total services which have been
rendered by the ENGINEER shall be mutually agreed by the parties hereto. The fixed fee stipulated in Section 4d of THE
LA AGREES shall be multiplied by this percentage and added to the ENGINEER'S actual costs to obtain the earned value
of work performed. All field notes,test records and reports completed or partially completed at the time of termination shall
become the property of, and be delivered to,the LA.
5. That any differences between the ENGINEER and the LA concerning the interpretation of the provisions of this
AGREEMENT shall be referred to a committee of disinterested parties consisting of one member appointed by the
ENGINEER, one member appointed by the LA, and a third member appointed by the two other members for disposition and
that the committee's decision shall be final.
6. That in the event the engineering and inspection services to be furnished and performed by the LA (including personnel
furnished by the ENGINEER)shall,in the opinion of the STATE be incompetent or inadequate, THE STATE shall have the
right to supplement the engineering and inspection force or to replace the engineers or inspectors employed on such work
at the expense of the LA.
7. That the ENGINEER has not been retained or compensated to provide design and construction review services relating to
the Contractor's safety precautions, except as provided in Section 1 f of the ENGINEER AGREES.
Successors and Assigns
That the LA and the ENGINEER bind themselves,their successors, executors, administrators, and assigns to the other party
of this AGREEMENT, and to the successors, executors, administrators, and assigns of such other party in respect to all
covenants of this AGREEMENT.
Executed by the LA: City of Elgin of the
(Municipality/Township/County)
ATTEST: State of Illinois, acting-k�'anc�.,
throng �C C�
By: 9/60(-61A---- ; By: '
Clerk Title:
(SE )
Executed by the ENGINEER: BRW, INC.
1701 Golf Road,Suite 1000
ATTEST: Rolling Meadows, Illinois 60008
By: G,Ju.7-e- By: "ide4.Title: Title
n� Mo,,.7 7/%e7 ity�/'-moo" /4‘._
BLR 4352(Rev. 11/89)
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Federal-Aid Project CMM-7003(491)
Certification of Engineer
I hereby certify that I am the Senior Project Manager and duly authorized representative of the firm of BRW, INC.,whose address
is 1701 Golf Road, Suite 1000, Rolling Meadows, Illinois 60008, and that neither I nor the firm I herein represent has:
(a) employed or retained for a commission, percentage, brokerage, contingent fee, or other considerations, any firm
or person (other than a bona fide employee working solely for me or the above ENGINEER)to solicit or secure
this AGREEMENT,
(b) agreed,as an express or implied condition for obtaining this AGREEMENT,to employ or retain the services of any
firm or person in connection with carrying out the AGREEMENT, or
(c) paid,or agreed to pay to any firm,organization or person (other than a bona fide employee working solely for me
or the above ENGINEER (any fee, contribution,donation, or consideration of any kind for, or in connection with,
procuring or carrying out the AGREEMENT.
In addition, I and the firm I herein represent:
(d) are not presently debarred,suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
covered transactions by any Federal department or agency;
(e) have not within a three-year period preceding this AGREEMENT been convicted of or had a civil judgement
rendered against them for commission of fraud or criminal offense in connection with obtaining, attempting to
obtain or performing a public(Federal,State or local)transaction or contract under a public transaction: violation
of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or
destruction or records, making false statements, or receiving stolen property;
(f) are not presently indicted for or otherwise criminally or civilly charged by a governmental entity(Federal, State or
local)with commission of any of the offenses enumerated in paragraph (e) of this certification;
(g) have not within a three-year period preceding this AGREEMENT had one or more public transactions (Federal,
State or local)terminated for cause or default;
Where the ENGINEER is unable to certify to any of the statements in this certification, such ENGINEER shall attach an
explanation to this AGREEMENT.
I acknowledge that this certificate is to be furnished to the LA and the STATE, in connection with this AGREEMENT involving
participation of Federal-aid highway funds, and is subject to applicable State and Federal laws, both criminal and civil.
V`f/9(5 (Date) (Signature)
Certification of LA
I hereby certify that I am the /1 ( (A- of City of Elgin
(County Board Chairman/MayorNillage President) (County/Municipality/Township)
and that the above ENGINEER or his representative has not been required directly or indirectly as an express or implied condition
in connection with obtaining or carrying out this AGREEMENT to:
(a) employ or retain, or agree to employ or retain, any firm or person, or
(b) pay, or agree to pay, to any firm, person or organization, any fee, contribution, donation, or consideration of any kind;
except as herein expressly states (if any);
I acknowledge that this certificate is to be furnished to the STATE, in connection with this AGREEMENT involving participation
of Federal-aid highway funds, and is subject to pplicable State and Federal laws, both criminal and civil.
25 4t (Date) i /����
(Signature)
BLR 4352(Rev. 11/89)
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STATE OF ILLINOIS
DRUG FREE WORKPLACE CERTIFICATION
This certification is required by the Drug Free Workplace Act(III. Rev. Stat., ch. 4. the penalties that may be imposed upon an employee for drug violations.
127, par. 152.311). The Drug Free Workplace Act, effective January 1, 1992,
requires that no grantee or contractor shall receive a grant or be considered for the C. Providing a copy of the statement required by sub-paragrapl-r (a) to each
purposes of being awarded a contract for the procurement of any property or employee engaged in the performance of the contract or grant and to post the
services from the State unless that grantee or contractor has certified to the State statement in a prominent place in the workplace.
that the grantee or contractor will provide a drug free workplace. False certification
or violation of the certification may result in sanctions including, but not limited to, D. Notifying the contracting or granting agency within ten (10) days after receiving
suspension of contract or grant payments,termination of the contract or grant and notice under part (b) of paragraph (3) of subsection (a) above from an
debarment of contracting or grant opportunities with the State for at least one (1) employee or otherwise receiving actual notice of such conviction.
year, but not to be more than five (5)years.
E. Imposing a sanction on, or requiring the satisfactory participation in a drug
For the purpose of this certification,"grantee" or"contractor" means a corporation, abuse assistance or rehabilitation program by, an employee who is so
partnership, or other entity with twenty-five (25) or more employees at the time of convicted, as required by section 5 of the Drug Free Workplace Act.
issuing the grant, or a department, division, or other entity with twenty-five (25) or
more employees at the time of issuing the responsible for the specific performance F. Assisting employees in selecting a course of action in the event drug
under a contract or grant of$5,000 or more from the State. counseling, treatment, and rehabilitation is required and indicating that a
trained referral team is in place.
The contractor/grantee certifies and agrees that it will provide a drug free
workplace by: G. Making a good faith effort to continue to maintain a drug free workplace
through implementation of the Drug Free Workplace Act.
A. Publishing a statement:
1. notifying employees that the unlawful manufacture, distribution,dispensing, THE UNDERSIGNED AFFIRMS, UNDER PENALTIES OF PERJURY,THAT HE
possession or use of a controlled substance, including cannabis, is OR SHE IS AUTHORIZED TO EXECUTE THIS CERTIFICATION ON BEHALF OF
prohibited in the grantee's or contractor's workplace; THE DESIGNATED ORGANIZATION.
2. specifying the actions that will be taken against employees for violations of BRW, INC.
such prohibition; Printed Name of Organization
3. notifying the employee that,as a condition of employment on such contract
or employee grant,the will: Signatur of thorized Representative
a. abide by the terms of the statement; and George J. Schober/Senior Project Manager
Printed Name and Title
b. notify the employer of any criminal drug statute conviction for a violation
occurring in the workplace no later than five (5) days after such F --1/ 41 I 2 5Z12-
conviction; Requisition/Contract/Grant ID Number
B. Establishing a drug free awareness program to inform employees about: 2--4 it-4L
Date
1. the dangers of drug abuse in the workplace;
2. the grantee's or contractor's policy of maintaining a drug free workplace;
3. any available drug counseling, rehabilitation, and employee assistance
programs; and
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Exhibit A
Construction Engineering
Route * Firm's approved rates on file with
Local Agency City of Elgin U.S. Route 20 Bike Path IDOT's Bureau of Accounting and
(Municipality/Township/County) City of Elgin Auditing:
Section: 97-00160-00-BT Payroll Burden & Fringe Rate 0/0
Project: CMM-7003(491) Overhead & Expense Rate cyo
Job No.: C-91-261-97 * IDOT Approved Combined Rate = 155.09%
Cost Estimate of Consultant's Services in Dollars
Pay- Pay- Payroll Burden,
Employee Man- Roll Roll Overhead &
Element of Work Classification Hours Rate Costs Fringe Costs Profit Total
Construction Engineering See Exh. B 36 26.21 944 1,464 315 2,723
Construction Survey See Exh. B 48 19.67 944 1,464 315 2,723
Inspection See Exh. B 120 21.53 2,584 4,008 862 7,454
Documentation Reports and Shop Drawings See Exh. B 44 24.17 1,063 1,649 354 3,066
Vehicles See Exh. D 600
Material Testing 1,784
Estimate of Manhours based on the Scope of Services/Manhour Summary-
Exhibit C
248 5,535 8,585 _ 1,846 18,350
BLR 4352 (Rev. 11/89)
**Complexity Factor, r= 0.00 (Sheet 7 of 7)
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EXHIBIT B
AVERAGE HOURLY PROJECT RATES
CONSTRUCTION ENGINEERING
U.S. ROUTE 20 BIKE PATH
City of Elgin
ITEM 1 ITEM 2 ITEM 3 ITEM 4
CLASSIFICATION SAL-
ARY CONSTRUCTION CONSTRUCTION INSPECTION DOCUMENTATION
ENGINEERING SURVEY REPORTS &
SHOP DRAWINGS
WGT. % WGT. % WGT. % WGT.
PART RATE PART RATE PART RATE PART RATE
PROJECT MANAGER 34.61 33.34 11.54 I 27.27 9.44
RESIDENT ENGINEER 22.00 66.66 14.67 66.66 14.67 93.33 20.53 54.55 12.00
CONSTRUCTION/SURVEY
TECHNICIAN 15.00 33.34 5.00 6.67 1.00 18.18 2.73
AVERAGE PAYROLL
RATE 100.00 26.21 100.00 19.67 100.00 21.53 , 100.00 24.17
BRW, Inc.
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EXHIBIT C
CITY OF ELGIN
U.S. ROUTE 20 BIKE PATH
PROBABLE CONSTRUCTION SCHEDULE
CHARGEABLE WORKDAYS
LETTING JUNE 12,1998 (30 TOTAL) MONTH JULY AUGUST SEPTEMBER
BEGIN CONSTRUCTION JULY 27,1998 WEEK ENDING (2) (16) (12)
COMPLETE CONSTRUCTION SEPTEMBER 18,1998 ON FRIDAY 7/27 8/7 8/14 8/21 8/28 9/4 9/11 9/18
TOTAL DAILY REQUIRED
CONSTRUCTION ITEM QUANTITY RATE WORK DAYS
TREE REMOVAL(6"TO 15") 436 UNIT 150 1 — '
10
EARTH EXCAVATION 1,980 C.M. 350 6
AGGREGATE BASE COURSE 6,600 S.M. 550 12
BITUMINOUS CONCRETE SURFACE COURSE 832 M.TON 120 7
FURNISHING AND PLACING TOPSOIL(4") 4,400 S.M. 1,000 2 _ --II.
PAVEMENT MARKINGS/SIGNING — --- --- 1 --I.
CLEAN UP/PUNCHLIST — --- — 1 ---►
R:\projects\elgin\rt20bike\constsch.wk4
EXHIBIT C
CITY OF ELGIN
U.S.ROUTE 20 BIKE PATH
PROBABLE CONSTRUCTION STAFFING
CHARGEABLE WORKDAYS
(30 TOTAL)
BEGIN CONSTRUCTION JULY 27,1998 MONTH JULY AUGUST SEPTEMBER
COMPLETE CONSTRUCTION SEPTEMBER 18,1998 WEEK ENDING (2) (16) (12)
ON FRIDAY 7/20 7/27 8/7 8/14 8/21 8/28 9/4 9/11 9/18 9/25
TOTAL
TECHNICAL STAFF MANHOURS
Resident Engineer 192 12 20 20 20 20 20 20 20 20 20
Construction/Survey Technician 32 8 8 8 8
Project Manager 24 4 2 2 2 2 2 2 2 2 4
TOTALS 248 24 30 22 30 22 22 22 22 22 32
R:\projects\elgin\rt20bike\constsch.wk4
VEHICLE COST
Average Monthly Ownership Cost = $ 310.00
Average Monthly Insurance Cost = 110.00
Average Monthly Maintenance (Operating Cost) = 210.00
$ 630.00
Based on 21 days per month vehicle use, the daily cost = $30.00
1 Vehicle - 20 days x $30.00/day = $600.00
TOTAL VEHICLE COSTS: $600.00
EXHIBIT D
R:\projects\elgin\rt2Obike\ag mt,wpd
TSC
TESTING SERVICE CORPORATION
February 4, 1998
CORPORATE OFFICE:
360 S. Main Place, Carol Stream, IL 60188-2404
630.462.2600 • Fax 630.653.2988
Mr. David Nissen
BRW, Inc.
One Continental Tower
1701 Golf Road, Suite 1000
Rolling Meadows, Illinois 60008
RE: P.N. 19,028
Rt US 20-Bike Path
Elgin,Illinois
Dear Mr.Nissen:
Per your request,Testing Service Corporation(TSC) is pleased to submit this proposal to provide the
Construction Materials Engineering Services that will be requested by you for the above referenced project.
The broad objectives of our work will be to conduct and interpret tests and report our findings as directed by
BRW, Inc. personnel.
TSC is staffed and equipped to provide any of the following services that may be ordered by you:
• Field Quality Control Services
-Observe proof-rolling operations.
-Recommend amount of undercut using IDOT cone penetrometer procedure.
-Perform in-place density tests on engineered fill/backfill and granular base course
-Test plastic concrete for slump,air content,temperature,unit weight and cast test cylinders.
-Establish rolling pattern for bituminous concrete pavement mix with nuclear density gauge.
-Pickup samples in the field for laboratory tests.
• Bituminous Concrete Batch Plant Quality Control Services
-Daily hot bin and extraction analysis.
-Sampling and testing of stockpile materials.
-Check and adjust mixing formulas,as necessary.
-Check temperatures of bitumen, drum and final mix.
-Mold Marshall samples and check for stability and flow.
-Other tests as required by current IDOT procedures guide.
• Portland Cement Concrete Batch Plant Quality Control Services
-Verify that current IDOT mix design is being used.
-Check moisture content of fine aggregate.
-Perform sieve analysis on stockpiled materials, as required by IDOT criteria.
-Check the slump,air and temperature of final mix.
-Other tests, as required by current IDOT procedure guide.
• Laboratory
-Perform laboratory compaction curve for each soil type used.
-Determine density and thickness for core samples submitted by contractor.
-Aggregate gradation and soundness analysis.
-Perform compressive and flexural strength tests for concrete cylinders and beams.
-Other tests, as required.
Providing a Full Range of Geotechnical Engineering, Environmental Services, and Construction Materials Engineering & Testing
,BRW, Inc.
P.N. 19,028 - February 4, 1998
Supervision of the testing, observation and reporting is provided by a Registered Professional Engineer.
Reports will generally be issued on a weekly basis as work progresses. Invoices will be issued monthly,
subsequent to the reporting period.
A budget amount of One Thousand Seven Hundred Eighty Four dollars and fifteen cents($1,784.15) is
recommended for your project. This estimate is based on a review of project quantities provided by BRW, Inc.
and prior experience on similar projects. TSC's itemized estimate is included in the"Assumptions and
Estimated Fee" portion of this proposal. Factors such as weather,contractor efficiency and deviations from
minimum testing and observation requirements may significantly impact the CME budget.
TSC's fees include TSC's services being performed subject to the attached General Conditions which are
incorporated herein. Unless we receive written instructions to the contrary, invoices will be sent to:
Mr. David Nissen
BRW,Inc.
One Continental Tower
1701 Golf Road, Suite 1000
Rolling Meadows,Illinois 60008
When completing the attached project data form,kindly indicate who is to receive copies of TSC's report and other
project data.
Your consideration of our proposal is appreciated. We look forward to being of service to you on this project.
Respectfully Submitted
TESTING S VICE CORPORATION Prepared By
g "I'
Allen L. DuBos t, John . Moky
President (7 Section Manager
ALD:JWM:kw
Approved and accepted for by:
(NAME)
(TITLE)
(DATE)
-2-
•
BJ.W,Inc.
' P.N. 19,028 - February 4, 1998
SCHEDULE OF CHARGES
ITEM I FIELD SERVICES
A. Construction Materials Engineering(CME)Technician Per Hour: $ 35.75
B. IDOT BIT or PCC Certified Per Hour: $ 37.00
C. IDOT QC/QA Level I BIT or PCC Per Hour: $ 40.00
D. IDOT QC/QA Level II BIT or PCC Per Hour: $ 45.00
CME Technician classification includes IDOT BIT/PCC and QC/QA Certified Technicians.
Time is portal-to-portal from the office servicing the project. Increase hourly rate by 1.3 for
over 8.0 hours per day,Saturday and/or Sunday work. Holiday work is 1.5 times standard
rate. The minimum trip charge is three(3)hours. Engineering services for summary report
preparation and project administration are invoiced at the Graduate Engineer Rate.
E. Transportation, Light Vehicle Per Mile: $ 0.40
F. Use of Nuclear Moisture/Density Gauge Per Day: $ 35.00
G. Pickup Concrete Test Samples Per Trip: $ 40.00
ITEM II LABORATORY SERVICES
A. Soils
1. Compaction Curve to establish the maximum
dry unit weight and optimum water content
a. Modified(AASHTO T180,ASTM D1557) Each: $ 130.00
b. Standard(AASHTO T99,ASTM D698) Each: $ 110.00
c. Add for Methods B,C,or D Each: $ 15.00
2. Thin-Walled Tube Samples
a. Combined Water Content&Dry Unit Weight Determination Each: $ 11.50
b. Unconfined Compressive Strength Each: $ 11.00
B. Portland Cement Concrete/Aggregates
1. Concrete Cylinders
a. Compressive Strength Each: $ 9.50
b. Spares/Handling Charge Each: $ 9.50
c. Trim End of Specimen When Necessary Each: $ 15.00
-3-
•
,BRW,Inc.
P.N. 19,028 - February 4, 1998
2. Sieve Analysis
a. Unwashed Each: $ 40.00
b. Washed Each: $ 55.00
C. Bituminous Concrete
1. Extraction Analysis Each: $ 95.00
2. Stability Flow and Bulk Density(Marshall Method)
a. 3 Specimens per Mix Per Test: $ 125.00
b. With Percent Voids&Theoretical Maximum Density Add: $ 50.00
3. Density of Core Specimen Each: $ 20.00
ITEM III CONSULTATION AND REPORT PREPARATION
A. Dr. Lawrence A. DuBose,P.E., S.E. Per Hour: $ 125.00
B. Registered Professional Engineer,Principal Per Hour: $ 95.00
C. Registered Professional Engineer Per Hour: $ 80.00
D. Graduate Civil Engineer Per Hour: $ 70.00
E. Transportation
1. Light Vehicle Per Mile: $ 0.40
2. Public Transportation Cost+ 10%
The above rates are valid through March 31, 1998
-4-
,BRW, Inc.
P.N. 19,028 - February 4, 1998
ASSUMPTIONS & ESTIMATED FEE
The following estimate is based on review of materials quantities provided by the BRW, Inc. and the Illinois
Department of Transportation's Project Procedures Guide. At the time this estimate was prepared the contractor's
schedule was not available.
Earth Excavation/Aggregate Base Course/Trench Backfill
Item
No. ITEMS Unit Quantity No. Amount
1 CME Technician Hour 6.0 35.75 $ 214.50
2 Travel,CME Technician Hour 3.0 35.75 $ 107.25
3 Travel,Light Vehicle Mile 64 0.40 $ 25.60
4 Soil, Water Content Determination Each 7 4.50 $ 31.50
Sub-Total: $ 378.85
Estimate Basis:Estimate two 3 hour trips to the site.
Bituminous Concrete/Plant
Item ITEMS Unit Quantity PUr nit Amount
ice
1 IDOT Certified Technician Hour 14.0 37.00 $ 518.00
2 Travel,IDOT Certified Technician Hour 3.0 37.00 $ 111.00
3 Travel, Light Vehicle Mile 112 0.40 $ 44.80
4 Nuclear Moisture Density Gauge Day 2 17.50 $ 35.00
5 Bituminous Concrete Extraction Analysis Each 1 95.00 $ 95.00
6 Marshall Determination, Set of 3 r Each 1 125.00 $ 125.00
7 Maximum Specific Gravity of Bituminous Mixture Each 1 50.00 $ 50.00
Sub-Total: $ 978.80
Estimate Basis:Estimate two 7 hour trips to the plant and site.
-5-
,BRW,Inc.
P.N. 19,028 - February 4, 1998
Portland Cement Concrete/Plant
Item
No. ITEMS Unit Quantity Unit Amount
Price
1 IDOT QC/QA Technician Hour 2.0 37.00 $ 74.00
2 Travel,QC/QA Technician Hour 1.5 37.00 $ 55.50
3 Travel, Light Vehicle Mile 40 0.40 $ 16.00
4 Sieve Analysis with#200 Wash Each 1 55.00 $ 55.00
Sub-Total: $ 200.50
Estimate Basis:Estimate one 2.5 hour trip to the plant.
Portland Cement Concrete/Field
Item
No. ITEMS Unit Quantity prnit Amount
1 Pickup Test Samples Each 2 40.00 $ 80.00
2 Concrete Test Samples Each 8 9.50 $ 76.00
Sub-Total: $ 156.00
Estimate Basis:Estimate 0 trips to the site.
Project Coordination&Report Preparation
Item
No. ITEMS Unit Quantity Unite Amount
1 Project Engineer Hour 1 70.00 $ 70.00
2 Secretary N/C $ 0.00
Sub-Total: $ 70.00
TSC's base fee schedule includes up to three copies of each report.
Estimated Total: $ 1,784.15
RECOMMENDED BUDGET: $ 1,784.15
-6-
ITSC) Chu' Q1 �'OaDO�'OOGO
Geotechnical and Construction Services
TESTING SERVICE CORPORATION
•
1. PARTIES AND SCOPE OF WORK:"This Agreement" consists of Testing Service 9.SAMPLE DISPOSAL:Unless otherwise agreed in writing,test specimens or samples will be
Corporation's ("TSC") proposal,TSC's Schedule of Fees and Services, Client's written disposed immediately upon completion of the test.All drilling samples or specimens will be
acceptance thereof,if accepted by TSC,and these General Conditions.The terms contained disposed sixty(60)days after submission of TSC's report.
in these General Conditions are intended to prevail over any conflicting terms in this
Agreement."Client"refers to the person or entity ordering the work to be done or professional 10.TERMINATION:This Agreement may be terminated by either party upon seven days prior
services to be rendered by TSC (except where distinction is necessary, either work or written notice.In the event of termination,TSC shall be compensated by Client for all services
professional services are referred to as"services"herein).If Client is ordering the services performed up to and including the termination date,including reimbursable expenses.
on behalf of another,Client represents and warrants that Client is the duly authorized agent •
of said party for the purpose of ordering and directing said services,and in such case the 11.PAYMENT:Client shall be invoiced periodically for services performed.Client agrees to pay
term"Client"shall also include the principal for whom the services are being performed. each invoice within thirty(30)days of its receipt.Client further agrees to pay interest on all
Prices quoted and charged by TSC for its services are predicated on the conditions and the amounts invoiced and not paid or objected to in writing for valid cause within sixty(60)days at
allocations of risks and obligations expressed in these General Conditions.Unless otherwise the rate of twelve(12%)per annum(or the maximum interest rate permitted by applicable law,
stated in writing,Client assumes sole responsibility for determining whether the quantity whichever is the lesser)until paid and TSC's costs of collection of such accounts,including
and the nature of the services ordered by Client are adequate and sufficient for Client's court costs and reasonable attorney's fees.
intended purpose.Client shall communicate these General Conditions to each and every
third party to whom the Client transmits any report prepared by TSC.Unless otherwise 12.WARRANTY:TSC's professional services will be performed,its findings obtained and its
expressly assumed in writing,TSC shall have no duty to any third party,and in no event shall reports prepared in accordance with this Agreement and with generally accepted principles and
TSC have any duty or obligation other than those duties and obligations expressly set forth practices.In performing its professional services,TSC will use that degree of care and skill
in this Agreement.Ordering services from TSC shall constitute acceptance of TSC's proposal ordinarily exercised under similar circumstances by members of its profession.In performing
and these General Conditions. physical work in pursuit of its professional services,TSC will use that degree of care and skill
ordinarily used under similar circumstances.This warranty is in lieu of all other warranties or
2.SCHEDULING OF SERVICES:The services set forth in this Agreement will be accomplished representations,either express or implied.Statements made in TSC reports are opinions based
in a timely and workmanlike manner.If TSC is required to delay any part of its services to upon engineering judgment and are not to be construed as representations of fact.
accommodate the requests or requirements of Client,regulatory agencies,or third parties,
or due to any cause beyond its reasonable control,Client agrees to pay such additional Should TSC or any of its employees be found to have been negligent in performing professional
charges,if any,as may be applicable. services or to have made and breached any express or implied warranty,representation or
• contract,Client,all parties claiming through Client and all parties claiming to have in any way
3.ACCESS TO SITE:Client will arrange and provide such access to the site as is necessary relied upon TSC's services or work agree that the maximum aggregate amount of damages for
for TSC to perform its services.TSC shall take reasonable measures and precautions to which TSC,its officers,employees and agents shall be liable is limited to$50,000 or the total
minimize damage to the site and any improvements located thereon as a result of its services amount of the fee paid to TSC for its services performed with respect to the project,whichever
or the use of its equipment;however,TSC has not included in its fee the cost of restoration amount is greater.
of damage which may occur.If Client desires or requires TSC to restore the site to its former
condition,TSC will,upon written request,perform such additional work as is necessary to In the event Client is unwilling or unable to limit the damages for which TSC may be liable in
do so and Client agrees to pay to TSC the cost thereof plus TSC's normal markup for overhead accordance with the provisions set forth in the preceding paragraph,upon written request of
and profit. Client received within five days of Client's acceptance of TSC's proposal together with payment
of an additional fee in the amount of 5%of TSC's estimated cost for its services(to be adjusted
4.CLIENT'S DUTY TO NOTIFY ENGINEER:Client represents and warrants that Client has to 5%of the amount actually billed by TSC for its services on the project at time of completion),
advised TSC of any known or suspected hazardous materials,utility lines and underground the limit damages shall be increased to$500,000 or the amount of TSC's fee,whichever is the
structures at any site at which TSC is to perform services under this Agreement. greater.This charge is not to be construed as being a charge for insurance of any type,but is
increased consideration for the exposure to an award of greater damages.
5.DISCOVERY OF POLLUTANTS:TSC's services shall not include investigation for hazardous
materials as defined by the Resource Conservation Recovery Act,42 U.S.C.§6901,et,seq., 13.INDEMNITY:Subject to the provisions set forth herein,TSC and Client hereby agree to
as amended ("RCRA")or by any state or Federal statute or regulation.In the event that indemnify and hold harmless each other and their respective shareholders,directors,officers,
hazardous materials are discovered and identified by TSC,TSC's sole duty shall be to notify partners,employees,agents,subsidiaries and division(and each of their heirs,successors,and
Client. assigns)from any and all claims,demands,liabilities,suites,causes of action,judgments,costs
and expenses,including reasonable attorneys'fees,arising,or allegedly arising,from personal
6.MONITORING:If this Agreement includes testing construction materials or observing any injury,including death,property damage,including loss of use thereof,due in any manner to the
aspect of construction of improvements,TSC will report its test results and observations as negligence of either of them or their agents or employees.In the event both are negligent or at
more specifically set forth elsewhere in this Agreement.Client shall cause all tests and fault,then any liability shall be apportioned between them pursuant to their pro rata share of
inspections of the site,materials and work to be timely and properly performed in accordance negligence or fault.TSC and Client further agree that their liability to any third party shall,to the
with the plans,specifications,contract documents,and TSC's recommendations.No claims extent permitted by law,be several and not joint.The indemnities provided hereunder shall not
for loss,damage or injury shall be brought against TSC unless all tests and inspections have terminate upon the termination or expiration of this Agreement.
been so performed and unless TSC's recommendations have been followed.
14.SUBPOENAS:TSC's employees shall not be retained as expert witnesses except by separate,
TSC's services shall not include determining or implementing the means,methods,techniques written agreement.Client agrees to pay TSC pursuant to TSC's then current fee schedule for any
or procedures of work done by the contractor(s)being monitored or whose work is being TSC employee(s)subpoenaed by any party as an occurrence witness as a result of TSC's services.
tested.TSC's services shall not include the authority to accept or reject work or to in any
manner supervise the work of any contractor.TSC's services or failure to perform same 15.OTHER AGREEMENTS:TSC shall not be bound by any provision or agreement(i)requiring or
shall not in any way operate or excuse any contractor from the performance of its work in providing for arbitration of disputes or controversies arising out of this Agreement,(ii)wherein
accordance with its contract."Contractor"as used herein shall include subcontractors, TSC waives any rights to a mechanics lien or(iii)that conditions TSC's right to receive payment
suppliers,architects,engineers and construction managers. for its services upon payment to Client by any third party.These General Conditions are notice,
where required,that TSC shall file a lien whenever necessary to collect past due amounts.This
7.ROOF INVESTIGATIONS:Should it be necessary to make roof cuts,Client agrees to provide Agreement contains the entire understanding between the parties.Unless expressly accepted
a roofing contractor of Client's choice to make such cuts,to remove samples as directed by by TSC in writing prior to delivery of TSC's services,Client shall not add any conditions or
TSC personnel and to promptly make necessary patches or repairs.In the event that a roof impose conditions which are in conflict with those contained herein,and no such additional or
contractor is not so provided by Client,Client agrees that TSC may make and remove such conflicting terms shall be binding upon TSC.The unenforceability or invalidity of any provision or
cuts as TSC deems necessary in the course of the investigation and Client assumes all risks provisions shall not render any other provision or provisions unenforceable or invalid.This
of damage to the roof system and the building which may arise as a result thereof. Agreement shall be construed and enforced in accordance with the laws of the State of Illinois.
In the event of a dispute arising out of or relating to the performance of this Agreement,the
8.LIMITATIONS OF PROCEDURES,EQUIPMENT AND TESTS:Information obtained from breach thereof or TSC's services,the parties agree to try in good faith to settle the dispute by
borings, observations and analyses of sample materials shall be reported in formats mediation under the Construction Industry Mediation Rules of the American Arbitration Association
considered appropriate by TSC unless directed otherwise by Client.Such information is as a condition precedent to filing any demand for arbitration,or any petition or complaint with
considered evidence,but any inference or conclusion based thereon is,necessarily,an opinion any court.Should litigation be necessary,the parties consent to jurisdiction and venue in an
also based on engineering judgment and shall not be construed as a representation of fact. appropriate Illinois State Court in and for the County of DuPage,Wheaton,Illinois or the Federal
Subsurface conditions may not be uniform throughout an entire site and ground water levels District Court for the Northern District of Illinois.Paragraph headings are for convenience only
may fluctuate due to climatic and other variations.Construction materials may vary from and shall not be construed as limiting the meaning of the provisions contained in these General
the samples taken.Unless otherwise agreed in writing,the procedures employed by TSC Conditions.
are not designed to detect intentional concealment or misrepresentation of facts by others. rev.6/97
FTSC) Project Data Sheet
TESTING SERVICE CORPORATION
Distribute Reports as Follows:
General Information: Name:
Project Name: Company:
Project Address: Address:
City/State/Zip: City/State/Zip:
Project Manager: Telephone:
Telephone: Fax:
Fax:
Site Contact: Name: •
Telephone: Company:
Fax: Address:
Send Invoice To: City/State/Zip:
Purchase Order No: Telephone:
Attention: Fax:
Company:
Address: Name:
City/State/Zip: Company:
Telephone: Address:
Fax: City/State/Zip:
Important Notes: Telephone:
Fax:
Name:
Company:
Completed By: Address:
Signature: City/State/Zip:
Name Telephone:
Date: Fax: