HomeMy WebLinkAboutIowa Department of Transportation-9/26/2011 (2)Form 830435wd
06-02
Iowa Department of Transportation
STATEMENT OF COMPLETION AND FINAL ACCEPTANCE OF WORK
Contractor Peterson Contractors, Inc.
Kind of Work PCC Pavement - Grade/New
Letting Date 07/17/07
Specified/Approximate/Late Start Date 08/20/07
(Circle which type applies)
Actual Start Date 09/10/07
Field Completion Date 05/19/08
County Black Hawk
Contract I.D. 07-8155-698
Project No. (s) HDP -8155(698)-71-07
Accounting I.D. No. (s) 25438
Site No. (s)
00
Iowa DOT Contract Acceptance
Signature Si1Q:52,44?r�
9
Date:
!(. ,
Working Days Specified:
60
Project Engine
IA 01
District Construction Engineer
Working Days Charged:
59.5
Closure Days Specified:
Closure Days Charged:
Approved and Work Accepted on Behalf of the City of Waterloo
Waterloo
Signature
7this day of
S
':LVbliQv
Mayor
2011
Year
For Maintenance Use Only
This work and test reports have been reviewed. A price adjustment, as provided in Article 1105.04 of the standard
specifications, has been made in the amount of $ Acceptance is recommended.
Signature
Signature
District Maintenance Engineer
District Materials Engineer
Date
Date
Final payment will be made in accordance with Article 1109.09 following a review of the project reports and
subject to the provision of Article 1105.04.
For Central Office Use Only
Recorded Finance
Recorded Construction/Maintenance
NOTE: On county administered projects, the County Engineer is required to sign "Recommended for Acceptance"
and "Approved and Work Accepted on Behalf of the Board of Supervisors".
Project Engineer—Send original to District District — Forward original +2 copies to office of ConstructionlMaintenance and 2
copies bad( to Project Engineer.
L•twork\project1931221admntUS63-StmntCompl-AnalAc cept.docx
Recommended for Acceptance
Iowa DOT Contract Acceptance
Signature Si1Q:52,44?r�
9
Date:
!(. ,
Signature
Date:
Project Engine
IA 01
District Construction Engineer
Approved and Work Accepted on Behalf of the City of Waterloo
Waterloo
Signature
7this day of
S
':LVbliQv
Mayor
2011
Year
For Maintenance Use Only
This work and test reports have been reviewed. A price adjustment, as provided in Article 1105.04 of the standard
specifications, has been made in the amount of $ Acceptance is recommended.
Signature
Signature
District Maintenance Engineer
District Materials Engineer
Date
Date
Final payment will be made in accordance with Article 1109.09 following a review of the project reports and
subject to the provision of Article 1105.04.
For Central Office Use Only
Recorded Finance
Recorded Construction/Maintenance
NOTE: On county administered projects, the County Engineer is required to sign "Recommended for Acceptance"
and "Approved and Work Accepted on Behalf of the Board of Supervisors".
Project Engineer—Send original to District District — Forward original +2 copies to office of ConstructionlMaintenance and 2
copies bad( to Project Engineer.
L•twork\project1931221admntUS63-StmntCompl-AnalAc cept.docx