Attachment A – Construction Waste Management Form
NO
CONSTRUCTION & DEMOLITION DEBRIS RECYCLING
APN: Building Permit #:________________________J#_________________ (if applicable) Date:_________________________ Owner Name: Owner Mailing Address: Phone ( )
Jobsite Contact: Company: Phone ( )
Jobsite Address: Type: Residential Non-Residential
Non-
Residential
Any new construction, demolition, addition, or alteration that requires a permit
Universal Waste (Fluorescent lamps, ballasts,
thermostats) must be sent to appropriate facility.
Residential Any new construction project that requires a permit Any demolition projects that require a permit
conditioned area, volume, or size
O
Only
Will you use a Richmond
= Sanitary Service debris box?
Will you haul your construction
& demolition waste yourself?
1) Fill out the Pre-Construction Waste Management Plan. 2)
3) When scheduling final inspection, submit receipts/weight tickets from the transfer station to verify waste 1) Fill out the Pre-Construction Waste Management Plan. 2) When scheduling final inspection, submit the Post Construction Waste Management Report AND submit receipts/weight tickets from the transfer station to verify . 3) Certify that the information is accurate and meets the current regulation.
YES
Does your project meet any
of the below criteria?
YES Fill out the rest of this form. If no, check this box: The below criteria do not apply to my project.1 2 3
YES
Page ATT A-3
Pre-Construction Waste Management Plan
Effective January 1, 2017, certain residential and non-residential building construction and demolition projects must meet Title 24 California Green Building Standards Code (CALGreen). For these projects, 65% of all waste generated must be recycled.
Specify in the table below the types and quantities of materials expected to be generated in your project. Indicate whether they will reused on-site, recycled or disposed. Also indicate the facility to be used.
Material Reuse Recycle Dispose Facility/Service Providers to be used Asphalt
Brick
Cardboard
Carpet
Concrete/Shotcrete
Dirt/Clean Fill
Gypsum Dry Wall **
Job office paper, glass & plastic bottles,
cans Collect separately
Metals
Plant/ Tree Debris
Roofing asphalt composition shingle, tile, wood
shake, tar or gravel
Rock/Stone
Wood (Pallets, lumber) **
Other
Page ATT A-4
Post Construction Waste Management ReportAPN: Building Permit #:_____________________J#_______________(if applicable)Date:___________________Owner Name: Owner Mailing Address: Phone ( ) Jobsite Contact: Jobsite Address: Phone ( )This form must be filled out if contractor does not use Richmond Sanitary Service debris box service. Permit will not be finalized until this completed report is submitted with receipts. If RSS debris box service is used, submit receipts. Further instructions are on the back of this form. MaterialReuseRecycleDisposeActual Facility/Service ProvidersUsedWeight (tons)AsphaltBrickCardboardConcrete/ ShotcreteDirt/Clean FillGypsum Dry WallJob office paper, glass & plastic bottles, cans, otherMetalPlant /Tree DebrisRoofing -asphalt composition shingle, tile, woodshake, tar or gravelRock/stoneWood(pallets, lumber, etc)OtherOtherMaterial Recovery SummaryTotal tons of materials disposed (not recycled):Total tons of materials salvaged, reused, or recycled:Percentage of materials recycled/reused: %Calculate pounds disposed per square footage of project _____________I certify that I have read the CalGreen Title 24 Building Code and understand the requirements of Section 4.408, 5.408, 301.1.1 and 301.3. The information I have provided is accurate to the best of my ability and meets the regulations. Contractor signature:_________________________________________Date:_________Contractor license #:__________________________ Page ATT A-5
Post Construction Waste Management Report Instructions Upon completion of construction and demolition activities, but before the final inspection, the person responsible for the project must submit the Post Construction Waste Management Report to the CDevelopment Services Department for review. Include the required documentation (listed below) to demonstrate achievement of the diversion requirement. Indicate the types and quantity of debris that were actually generated from the project (tons).Specify whether each material was reused, recycled or disposed. If the materials were reused on site, describe the reuse application under the Salvaged materials from deconstruction should be designated as reuse.Provide the name of each facility or service that was actually used for each type of material.Attach receipts or gate-tags for all materials to verify their destination including subcontractors loads.Provide any additional information (including photographs) that are relevant to determining compliance with the code.Calculate the percentage of materials recycled/reused.Sign the form certifying the information is accurate and meets the code.Mixed C&D materials are sorted, recycled, and reused if garbage is kept separated. Metals Cardboard Sheetrock Wood Page ATT A-6 FY22-23 Citywide Slurry Seal 2022 Form ATTACHMENT B – CHANGE Project No. 0602 ORDER FORM
Attachment B – Change Order Form
Contractor:Contractor NameContract Execution Date:mm/dd/yyyyORIGINAL CONTRACT AMOUNT:$0.00CHANGE ORDER #1 TOTAL: $0.00CHANGE ORDER #2 TOTAL: $0.00CHANGE ORDER #3 TOTAL: $0.00CURRENT CONTRACT AMOUNT (PRIOR TO THIS CHANGE ORDER): $0.000 $0.00 LS $0.000 $0.00 N/A $0.00$0.00REVISED CONTRACT AMOUNT:$0.00ADJUSTMENT OF CONTRACT TIME OF COMPLETION: # working days mm/dd/yyyyIn accordance with Article 6 of the General Conditions of the Contract Documents, you are hereby directed to make the herein described changes to the plans, specifications, or scope of work contracted for within the terms of the subject Contract.DESCRIPTION OF CHANGECCO item #DESCRIPTION A. EXISTING CONTRACT<PROJECT TITLE>
B. CHANGES IN THE CONTRACT DOCUMENTSThis change order formalizes various instruction bulletins (IBs), field orders, authorized RCOs and extra work/ force account items. All of the work items described below are in progress or have been completed. ITEM #UNIT QTY.UNIT PRICEUNITNET CHANGE TO CONTRACT PROJECT # <###> CONTRACT CHANGE ORDER NO. #<##>
DESCRIPTION CCO item #NET CHANGE IN CONTRACT COST:
P:\CIP\0_CIP_Forms & Guidelines\03 Const Phase\Contract Change Order (CCO#) Template.xlsx PROJECT # <###>
CONTRACT CHANGE ORDER NO. #<##>
Action / Title Signature Date
Contractor Acceptance by:
Contractor Acceptance Date
Action / Title Signature Date
*Necessary if contingency funds are needed and the Change Order exceeds City Council approved contract value.
Attachments: <Title of Contractor Document>
Distribution:
Original: City Clerk
cc: Contractor
Engineering
Finance - increase PO #<###> by: $0.00
Project Inspector/ Construction Manager
Notes: City Council approved a contract value on mm/dd/yyyy of $###,### and 15% contingency of $##,###.
Contract value including this CO/Authorized Contract: 0 / 0 = #DIV/0! as this indicates less than a 15% increase.
Signature
Project Manager, Title
Recommended
Funding in approved capital project budget account (###-####-#####-###) is adequate to cover this change order.
CCO Template Updated 10/12/20
Matt Rodriguez, City Manager
Funding Approval*
Allan A. Panganiban, PW Director / City
Engineer
C. APPROVAL SECTION
The undersigned Contractor certifies under penalty of perjury that its statements and representations in this Change Order request are true and correct. Contractor warrants that this Change Order request is comprehensive and complete as to the Work or changes referenced herein, and agrees that any known or foreseeable costs, expenses, or time extension requests not included herein, are deemed waived. Contractor understands that submission of claims which have no basis in fact or which Contractor knows to be false may violate the False Claims Act, as set forth in Government Code sections 12650 et seq., and Chapter 3.17 of the San Pablo Municipal Code.
Name, Title
P:\CIP\0_CIP_Forms & Guidelines\03 Const Phase\
Contract Change Order (CCO#) Template.xlsx
FY22-23 Citywide Slurry Seal 2022 Form ATTACHMENT C – NOTICES Project No. 0602 Page 113
Attachment C – Staging Area & Agreement
TEMPORARY ACCESS AGREEMENT AND RIGHT OF ENTRY
2600 Moraga Road, San Pablo, CA as described in Exhibit A (" Property")
This Temporary Access Agreement and Right of Entry ("Agreement") is entered into as of <Date> between the City of San Pablo , a municipal corporation (" City") and <Contractor> . ("Grantee"). By this Agreement, City grants to Grantee the right to enter upon the Property shown on the attached and incorporated Exhibit "A" subject to the following terms and conditions:
1. Purpose. This Right of Entry and Temporary Access is granted to Grantee solely for the purpose of allowing Grantee and its representatives, contractors, consultants and agents (collectively "Grantee" for purposes of this Agreement) to use the Property for the purpo se of temporarily storing construction equipment, material and staging for the construction of the Church Lane/Willow Road and El Portal Drive/Mission Bell Road Intersection Improvements Project (HSIPL-5303 (020)) to the extent not inconsistent with the terms of this Agreement. This Agreement does not allow for any other use or work of any other nature on the Property. No hazardous materials shall be brought or handled at any time on the Property
2. Term. The Grantee's right of entry and right of access to the Property shall commence on <Date> and shall automatically terminate on <Date> . This Agreement is revocable immediate upon notice by City. Upon notice of revocation, Grantee shall suspend all activity on the Property immediately.
3. Condition of Property. Grantee shall make no improvements to the Property without City’s approval. Grantee shall be responsible for all damage to the Property and shall immediately restore the Property to its current condition at the expiration or termination of this Agreement, as directed by City.
4. Notice to City. The day that Grantee desires access to the Property, Grantee shall first contact Jimmy Zhou, 510-215-3069. City retains the right to enter the Property at all times.
5. Utilities and Other Expenses. Grantee agrees to pay for all costs related to use of the Property, including any utility costs.
6. Assumption of Risk Releases and Indemnity. On behalf of itself and its agents, representatives, assigns, employees and contractors, Grantee assumes all risk of loss or injury arising from its entry onto the Property. City, its officers, agents, contractors , volunteers and employees shall not be liable for any injury, sickness, disease or death or any person or damage to property directly or indirectly related to any act or failure to act arising from Grantee's entry or use of the Property. Grantee shall indemnify, hold harmless, and defend City, its officers, agents, contractors, volunteers and employees from and against any and all liability, costs, or expense for loss of or damage to property, or for liability, costs, or for injuries to, sickness, disease or death of any person (including, but not limited to, the property and employees of each party to this Agreement) arising or resulting from Grantee's entry on and use of the Property. This provision shall survive termination of this Agreement.
7. Insurance. This right to enter the Property shall not be effective until evidence of insurance acceptable to the City is provided . Grantee shall procure and maintain for the duration of the contract, insurance against claims for injuries to persons or damages to property which may arise
from or in connection with the Lessee’s operation and use of the leased premises. The cost of such insurance shall be borne by the Lessee.
a. Minimum Scope of Insurance. Coverage shall be at least as broad as:
i. Insurance Services Office Commercial General Liability coverage (occurrence Form CG 20 11 01 96).
ii. Workers’ Compensation insurance as required by the State of California and Employer’s Liability Insurance (for lessees with employees).
iii. Property Insurance against all risks of loss to any tenant improvements or betterments.
b. Minimum Limits of Insurance. Grantee shall maintain limits no less than:
i. General Liability : $2,000,000 per occurrence for bodily injury, personal injury, property damage and contractual liability. If Commercial General Insurance or other form with a general aggregate limit is used, either the general aggregate limit shall apply separately to this project/location, or the general aggregate limit shall be twice the required occurrence limit. If Grantee’s is working within 50 feet of a railroad right of way, the Grantee shall have removed any exclusion on their liability policy limiting coverage for work near a railroad, or shall provide a Railroad Protective Liability policy in favor of the City. Limits for such coverage shall be no less than $5,000,000.
ii. Workers’ Compensation as required by the State of California. The Workers’ Compensation policy shall be endorsed with a waiver of subrogation in favor of the entity for all work performed by the contractor, its employees, agents, and subcontractors.
iii. Employer’s Liability: $1,000,000 each accident, $1,000,000 policy limit bodily injury by disease, $1,000,000 each employee bodily injury by disease.
iv. Property Insurance: Full replacement cost with no coinsurance penalty provision for all personal property.
c. Deductibles and Self-Insured Retentions. Any deductibles or self-insured retentions must be declared to and approved by the City. At the op tion of the City, either: the insurer shall reduce or eliminate such deductibles or self -insured retentions as respects the City, its officers, officials, employees and volunteers; or the Grantee shall provide a financial guarantee satisfactory to the City guaranteeing payment of losses and related investigations, claim administration, and defense expenses.
d. Other Insurance Provisions . The general liability policy is to contain, or be endorsed to contain, the following provisions:
i. The City, its officers, officials, employees, volunteers, contractors and agents are to be covered as insureds with respect to liability arising out of ownership, maintenance, or use of that part of the premises leased to the lessee.
ii. The Grantee’s insurance coverage shall be primary insurance as respects the City, its officers, officials, employees, volunteers , contractors and agents . Any insurance or self-insurance maintained by the City its officers, officials, employees, volunteers , contractors and agents shall be in excess of the Grantee’s insurance and shall not contribute with it.
iii. Each insurance policy required by this clause shall be endorsed to state that coverage shall not be cancelled, except after thirty (30) day’s prior written notice has been provided to the City.
e. Acceptability of Insurers. Insurance is to be placed with insurers with a current A.M. Best’s rating of no less than A:VII, unless otherwise acceptable by City.
f. Verification of Coverage. Lessee shall furnish City with original certificates and amendatory endorsements affecting coverage required by this clause. The endorsements should be on forms provided by the City or on other than the City’s forms, provided those endorsements or policies conform to the requirements. All certificates and endorsements are to be received and approved by the City before work commences. However, failure to do so shall not operate as a waiver of these insurance requirements. The City reserves the right to require complete, certifie d copies of all required insurance policies, including endorsements affecting the coverage required by these specifications at any time.
g. Contractors and Subcontractors. Grantee's insurance shall cover work by its contractors and subcontractors or the contractors and subcontractors must provide evidence of meeting the insurance requirements set forth above.
f. Higher limits. If Grantee maintains higher limits than the minimums above, City requires and shall be entitled to coverage for the higher limit s maintained. Any available insurance proceeds in excess of the specified minimum limits of insurance and cov erage shall be available to City.
i. Subrogation. Grantee hereby grants to C ity a waiver of any right to subrogation which any insurer of Grantee may acquire against C ity by virtue of the payment of any los under such insurance. Grantee agrees to obtain any endorsement that may be necessary to affect this waiver of subrogation, but this provision applies regardless of whether or not the C ity has received a waiver of subrogation endorsement from the insurer.
j. Modification. Grantee reserves the right to modify these requirements at any time, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstance.
8. No Assignment. Grantee shall not assign or otherwise transfer any rights under this Agreement, and any purported assignment or transfer shall automatically revoke the right to enter the Property.
9. Compliance with Laws . Grantee shall obtain and maintain all permits and approvals required for the activities under this Agreement and shall comply with all laws and regulations now in effort or that may become effective during the term of this Agreement. Duties and obligatio ns imposed by this Agreement and rights and remedies available under this Agreement are in addition to, and not a limitation of duties, obligations, rights and remedies otherwise imposed or available by law.
Should any discharge, leakage, spillage, emiss ion or pollution of any type occur upon of from the Property due to Grantee's entry arid use of the Property, then Grantee, at its sole cost, shall clean all affected property to the satisfaction of the City and any governmental body having jurisdiction.
10. No Dedication. Nothing contained in this Agreement shall be deemed a gift or dedication of any portion of the Property to or for the general public or for any public purpose whatsoever.
11. Governing Law: This Agreement shall be construed and enforced in accordance with the laws of the State of California.
12. Attorneys' Fees. In the event that either party institutes any action, suit or other dispute resolution proceeding based on this Agreement against the other party, the prevailing party is entitled to receive all costs and expenses associated with the actions, suit or proceeding, but not limited to attorneys' fees and court costs.
13. No waiver. No waiver by any party, at any time, of any breach of any provision of this Agreement shall be deemed a waiver or b reach of any other provision or consent to a subsequent breach of the same or another provision. If any action by any party shall require the consent or approval of another party, such consent or approval of such action on any one occasion shall not be deemed consent to or approval of such action on any subsequent occasion or consent or approval of any other action.
14. Agreement Construction . The parties acknowledge that this Agreement, as executed, shall not be construed for or against either party.
15. Amendment of Agreement. This Agreement may only be amended by a written instrument signed by both parties.
16. Entire Agreement. This Agreement represents the entire agreement between City and Grantee regarding entry upon the Property.
SIGNATURES ON NEXT PAGE
IN WITNESS WHEREOF, the parties have executed this Agreement as of the date written above first.
CITY: City of San Pablo
By:
Date:
GRANTEE:
By:
Date:
Exhibits:
A - Description of Property
EXHIBIT A
Description of Property
FY22-23 Citywide Slurry Seal 2022 Form ATTACHMENT D – NOTICES Project No. 0602 Page 114
Attachment D – Field Calibration Worksheets
Field Calibration Procedure Worksheets Job# Unit # Date: Aggregate Calibration **Minimum 50 counts of the Rock Belt counter per sample (3 Samples Per Gate Setting)** GATE SETTING (Inches) 3 Full Weight lbs Empty Weight lbs Net Weight lbs (=Full - Empty) No. of Counts lbs per Count Sample 1 Sample 2 Sample 3 Avg. Wet Agg. lbs/Count Moisture Factor Dry Agg. lbs/Count GATE SETTING (Inches) 4 Full Weight lbs Empty Weight lbs Net Weight lbs (=Full - Empty) No. of Counts lbs per Count Sample 1 Sample 2 Sample 3 Avg. Wet Agg. lbs/Count Moisture Factor Dry Agg. lbs/Count GATE SETTING (Inches) 5 Full Weight lbs Empty Weight lbs Net Weight lbs (=Full - Empty) No. of Counts lbs per Count Sample 1 Sample 2 Sample 3 Avg. Wet Agg. lbs/Count Moisture Factor Dry Agg. lbs/Count Data must be entered in the Full Weight, Empty Weight, and Number of Counts Columns. No additional Data is needed. ***Gate Settings and the Moisture Factor must be adjusted per Calibration*** ***Moisture Factor = Moisture Content (in decimal) 0.____+1.00***
Emulsion Calibration**Minimum 50 counts of the Rock Belt counter per sample** Emulsion Full Weight lbs Empty Weight lbs Net Weight lbs (=Full - Empty) No. of Counts lbs per Count Sample 1 Sample 2 Sample 3 Avg. lbs/Count of Emulsion Desired Emulsion % Data must be entered in the Full Weight, Empty Weight, and Number of Counts Columns. Desired emulsion percentage must also be entered. Cement/Fines Calibration **Minimum 10 counts of the Fines Feeder counter per sample** Cement/Fines Full Weight lbs Empty Weight lbs Net Weight lbs (=Full - Empty) No. of Counts lbs per Count Sample 1 Sample 2 Sample 3 Avg. lbs/Count of Fines Desired Cement/fines % Data must be entered in the Full Weight, Empty Weight, and Number of Counts Columns. Desired emulsion percentage must also be entered.
Equipment Calibration60.058.056.054.052.050.048.046.044.042.040.038.036.034.032.030.028.026.024.022.020.0 Gate Settings (Inches) Dry Aggregate Calibrations Wet Aggregate Calibrations Emulsion Calibration Fines Calibration
DAILY QUANTITIES JOB NUMBER PROJECT NAME DATE: QUANTITIES RECEIVED B.O.L. # DESCRIPTION OF MATERIALS Aggregate Emulsion % % % AGG EMULSION SURFACT FILLER MATERIALS ON HAND Tons Tons Gal # of Bags lbs/Bag Equipment # Counts lbs/count TOTAL USED AGG EMULSION SURFACT FILLER MATERIALS RECEIVED
TOTAL SQ YDS PLACED AVG. LBS (AGG) PER SQ YD TOTAL MIX TONS
TOTAL REMAINING