STATE OF NEVADA



STATE OF NEVADA

DEPARTMENT OF TRANSPORTATION

DISTRICT CONTRACT

SUB-CONTRACTOR APPROVAL FORM

Requests to subcontract at all tiers are to be made on this form DATE: ___________________

NDOT District Contract No. _______________________ Agreement No. _____________________________________________

Project No(s). __________________________________ Project Location: ___________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

The undersigned contractor hereby requests permission to sublet the following work items, which are a portion of the aforementioned district contract, to __________________________________________ Nevada Contractors’ License No. ______________________.

When contract items are to be sublet, contract unit prices and/or amounts are to be shown in the following tabulation:

|Item Number |Quantity |Unit |Item Description |Unit Price |Total Amount Contracted |

| | | |(If the item subcontracted is a partial performance, indicate the percentage| |for the Item |

| | | |of the Total Amount Contracted for the Item) | | |

| | | | | | |

| | | | | | |

| | | | | | |

| | | | | | |

Total amount sublet …………………………………………………………………………..… $ ____________________________

Less amount of specialty items sublet ………………………………………………………... $ ____________________________

Equals the total amount applicable to the 50% limitation ………………….…………….…. $ ____________________________

Qualifications of subcontractor: Has the subcontractor performed similar work? ___________ If so, with whom and in what amount,

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

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INCLUSION OF DISTRICT CONTRACT PROVISIONS IN SUB-CONTRACTS

It is agreed and understood, that the executed sub-contract and all lower tiered sub-contracts will contain, by inclusion, all of the terms and/or requirements including the following pertinent provisions, of the district contract number indicated and will be subject to the terms and requirements thereof:

1. Applicable federal or state prevailing wages as determined by the United States Department of Labor and/or as determined by the Office of the Labor Commissioner of the State of Nevada

2. Form FHWA-1273: Required Contract Provisions - Federal-Aid Construction Contracts (Sections I through XII)

3. STANDARD FEDERAL EQUAL EMPLOYMENT OPPORTUNITY CONSTRUCTION CONTRACT SPECIFICATIONS (EXECUTIVE ORDER 11246)

4. ADDITIONAL CONTRACT PROVISIONS - SPECIFIC EQUAL EMPLOYMENT OPPORTUNITY RESPONSIBILITIES

5. Subcontract Provisions NEVADA REVISED STATUTES

6. Notice to all subcontractors, material suppliers, labor unions, employees and applicants

7. TRAINING SPECIAL PROVISIONS

8. MINORITY BUSINESS ENTERPRISE IN FEDERAL-AID HIGHWAY CONSTRUCTION.

The undersigned agrees to provide certified payrolls for all employees working on this contracT.

__________________________________________ ___________________________________________ ______________

Name of contractor requesting to sublet Authorized Signature of requesting contractor Date

__________________________________________ ___________________________________________ ______________

Name of Sub-contractor Authorized Signature of Sub-contractor Date

___________________________________________ ______________

Signature of Project Coordinator Date

The sub-contracting contractor is to furnish a signed copy of this sub-contractor approval form to the NDOT Project Coordinator overseeing the district contract. Per NRS 408, the Project Coordinator must provide written approval for the sub-contractor request prior to the subcontractor actually starting work on the project.

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FOR NDOT DEPARTMENT USE ONLY:

NDOT District Contract amount …………………………….. $ _______________________________________________________

Less the total amount of specialty items for the contract ……. $ _______________________________________________________

Equals contract amount applicable to the 50% limitation ……. $ _______________________________________________________

Total amount sublet to date including this request is $ ________________________________ for a total of ___________ % of the permissible amount that can be sublet.

Approved by: ______________________________________________________ Date: _____________________

Contract Compliance Manager or Chief or Assistant Construction Engineer

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