Statement of Work - Attachment 9 - 01 33 00 - Attachment A - JB CHS Transmittal Form 4025

TRANSMITTAL OF SHOP DRAWINGS, EQUIPMENT DATA, MATERIAL SAMPLES, OR

MANUFACTURER'S CERTIFICATES OF COMPLIANCE

DATE

TRANSMITTAL NO.

The proponent agency is 628CES/CEN.
SECTION I - REQUEST FOR APPROVAL OF THE FOLLOWING ITEMS (This section will be initiated by the contractor) TO:

FROM:

CONTRACT NO.

CHECK ONE:

THIS IS A NEW TRANSMITTAL

THIS IS A RESUBMITTAL OF

TRANSMITTAL

SPECIFICATION SEC. NO. (Cover only one section with each transmittal)

THIS TRANSMITTAL IS FOR: (See Note 8)

PROJECT TITLE AND LOCATION

FIO

ITEM

NO.
(See
Note 3)

DESCRIPTION OF SUBMITTAL ITEM

(Model Number, Catalog Number, Manufacturer, Nomenclature of Material, etc.)

a.

b.

REMARKS

SUBMITTAL

TYPE CODE

(See Note 9)
c.

GA

CONTRACT DOCUMENT

REFERENCE

TYPE

OF

COPIES

(See Note 1)

d.

SPEC.
PARA. NO.

DRAWING

SHEET NO.

e.

f.

DA

CR

DA/CR

DA/GA

VARIATION

(See Note 6)

TIME/COST

IMPACT

(See Note 7)

GOV

ACTION

CODE

(Note 10)

g.

h.

i.

I certify that the above submitted items had been reviewed in detail and are correct and in strict conformance with the contract drawings and specifications except as otherwise stated.

NAME OF QC MANAGER

SIGNATURE OF QC MANAGER

SECTION II - APPROVAL ACTION

NAME AND TITLE OF APPROVING AUTHORITY

REMARKS

SIGNATURE OF APPROVING AUTHORITY

JB CHS TRANSMITTAL FORM 4025, 20210421

REPLACES AF IMT 3000, WHICH IS OBSOLETE.

DATE

NOTES

1. Indicate "E" For Electronically Submitted or "H-#” for hard copy (replacing “#” with the quantity) 2. Each Transmittal shall be numbered consecutively. If the Transmittal is a resubmittal, then add a decimal point to the end of the original Transmittal Number and begin numbering the resubmittal packages sequentially after the decimal. 3. The "Item No." for each entry on this form will be the same "Item No." as indicated on the submittal register. 4. Submittals requiring expeditious handling will be submitted on a separate Transmittal Form. 5. Items transmitted on each transmittal form will be from the same specification section. Do not combine submittal information from different specification sections in a single transmittal.
6. If the data submitted are intentionally in variance with the contract requirements, indicate a variation in column g, and enter a statement in the Remarks block describing he detailed reason for the variation.
7. If the variation causes an impact to time or cost indicate the type of impact in column h, and enter the associated RFI number in the remarks 8. Select one of the following depending on which approval source is required. FIO – For Information Only