Department of General Services Administration Division – OBAS CONSTRUCTION CONTRACT REQUEST FORM FORM C (REV 12.3.13) TYPE OF REQUEST: CONTRACT TYPE OFFICE NAME New Contract Contract Amendment BID AUTHORITY REQUESTER Construction Change Order Name: ABMS Encumberance/Disencumberance BID TYPE Phone: Closeout Contract Fax: AMENDMENT or CHANGE ORDER INFORMATION Cell: Contract Number: Email: Reason for Amendment: Backup Contact: Adjust Funding by: $ Name: Change Admin or Insurance Requirements (attach written details) Change Scope (attach written details) Phone: Extend Term to: Fax: Name and/or Address Change Cell: Change Order for Time/Materials (attach written details) Email: BRIEF DESCRIPTION OF REQUEST (max of 72 characters including punctuation and spaces. Note: a complete scope of work must be attached.) BID METHOD PREBID DETAILS CONTRACT DETAILS PAYMENT METHOD Mandatory Desired Start Date: Non-Mandatory Desired End Date: BID DETAILS RETENTION None Through Completion of Construction License Requirement: Date: Time: Rebid # Asbestos/DOSH cert req. % withheld CSLB/DCA license not req. Location: Term of Service (calendar days): % advance DSA LEA cert required Contract Staff Attendance requested Option to Extend Term: N/A for this request Technician Certification Security Clearance required at job walk Fiscal Agent Needed: Bid Opening Date: Security Clearance Required Bid Opening Location: PROJECT INFORMATION FUNDING TYPE (Match to project title used in the project manual.) (Check all that apply): Project Title: Federal Minor Capital Outlay Special Repairs Major Capital Outlay Client Agency: Support Other: Description: Bond City/County: If bond funded, is it a 2006 Infrastructure Bond? Full name of the bond/fund (source): Physical Address: Project Number: FISCAL USE ONLY: Estimated or Actual Cost: $ Proof of must be attached. State’s estimate (recently dated) Fund Source: ARF SRF Fund Number: Funding Document: ABMS Task Number: Item Number: Project Number: # Billing Code: Fiscal Year: Exp. Account Code: SRF Cost Center: Statute: Other: Multi-Region Cost Center: Chapter: Release Amount: Budget Analyst (Print Name):  Date PROGRAM APPROVAL By signing, I confirm I have reviewed this submission & supporting documents for completeness, accuracy & required approvals. (Original signatures required)  Requestor Submitting Form (Print Name): Date  Manager/Supervisor (Print Name): Date
Department of General Services – Administration Division OBAS CONSTRUCTION CONTRACT REQUEST FORM FORM C (REV 12.3.13) TYPE OF REQUEST: New Contract Contract Amendment Construction Change Order ABMS Encumberance/Disencumberance Closeout Contract CONTRACT TYPE BID AUTHORITY BID TYPE OFFICE NAME REQUESTER Name: Phone: Fax: AMENDMENT or CHANGE ORDER INFORMATION Contract Number: Reason for Amendment: Adjust Funding by: $ Change Admin or Insurance Requirements (attach written details) Change Scope (attach written details) Extend Term to: Name and/or Address Change Change Order for Time/Materials (attach written details) Cell: Email: Backup Contact: Name: Phone: Fax: Cell: Email: BRIEF DESCRIPTION OF REQUEST (max of 72 characters including punctuation and spaces. Note: a complete scope of work must be attached.) BID METHOD BID DETAILS License Requirement: Asbestos/DOSH cert req. CSLB/DCA license not req. DSA LEA cert required Technician Certification Bid Opening Date: Bid Opening Location: PREBID DETAILS Mandatory Non-Mandatory None Date: Time: Location: Contract Staff Attendance requested Security Clearance required at job walk CONTRACT DETAILS Desired Start Date: Desired End Date: Through Completion of Construction Rebid # Term of Service (calendar days): Option to Extend Term: Fiscal Agent Needed: Security Clearance Required PAYMENT METHOD RETENTION % withheld % advance N/A for this request PROJECT INFORMATION (Match to project title used in the project manual.) FUNDING TYPE (Check all that apply): Federal Minor Capital Outlay Special Repairs Major Capital Outlay Support Other: Bond If bond funded, is it a 2006 Infrastructure Bond? Full name of the bond/fund (source): Project Title: Client Agency: Description: City/County: Physical Address: Project Number: FISCAL USE ONLY: Estimated or Actual Cost: $ Proof of State’s estimate (recently dated) must be attached. Fund Source: ARF SRF Fund Number: Funding Document: ABMS Task Number: Item Number: Project Number: # Billing Code: Fiscal Year: Exp. Account Code: SRF Cost Center: Statute: Other: Multi-Region Cost Center: Chapter: Release Amount: Budget Analyst (Print Name):  Date PROGRAM APPROVAL By signing, I confirm I have reviewed this submission & supporting documents for completeness, accuracy & required approvals. (Original signatures required) Requestor Submitting Form (Print Name):  Date Manager/Supervisor (Print Name):  Date
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