FORM DOT 485



FORM DOT 485-A

REVISED 11/2007

STATE OF GEORGIA

DEPARTMENT OF TRANSPORTATION

REQUEST FOR APPROVAL OF 2ND TIER SUBCONTRACT

|CT. ID NO | |CONTRACT BID AMOUNT | |DATE LET | |

|PROJECT NO. | |COUNTY |

|PARENT (1ST TIER) SUBCONTRACT NO. | |SUBCONTRACT DATE | |

|SUPPLIER? |HAULER? | |

|SUBCONTRACT TYPE | |BONDED? YES NO |

|SUBCONTRACT AMOUNT $ |PERCENT THIS SUBCONTRACT      % |

| |

|2nd TIER SUBCONTRACT NO. | |2nd TIER SUBCONTRACT DATE | |

|SUPPLIER? |HAULER? | |

|2ND TIER SUBCONTRACTOR: | |VENDOR ID NO. | |

|ADDRESS: | |

|2ND TIER SUBCONTRACT TYPE |2ND TIER BONDED? YES NO |

|Only 60% of the participation of a DBE Supplier who does not manufacture or install the product will be counted toward the goal. |

|See the Contract for further instructions. |

| |

|This is notification that we, _______________________________________, have entered into a written agreement with the above mentioned company, whose Principal |

|Officer is ________________________ , Title: _______________, for certain work to be done on the above project on which we are a Subcontractor. |

AMOUNT

|THIS 2ND TIER SUBCONTRACTOR REQUEST | |

|2ND TIER SUBCONTRACTS PREVIOUSLY APPROVED | |

|1. | |

|2. | |

|3. | |

|4. | |

|5. | |

|TOTAL AMOUNT OF 2ND TIER SUBCONTRACTS | |

|We hereby certify that all other items of our Subcontract on the project will be performed by our forces with our own or rented equipment, except as may be |

|covered by other 2nd Tier subcontracts which you have approved or will be requested to approve. |

|We further certify that any applicable Federal Aid provisions have been attached to and made part of the Subcontract. |

| | |

|PRIME CONTRACTOR |SUBCONTRACTOR |

| | |

|SIGNED: ____________________________ DATE:______________ |SIGNED: ____________________________ DATE: __________ |

|(NAME & TITLE) |(NAME & TITLE) |

| |

|APPROVED - DISTRICT ENGINEER       |

| |

| |

|SIGNED: |

|DATE: |

CC: GENERAL FILES

PRIME CONTRACTOR

LIST 2nd TIER SUBCONTRACT ITEMS

Check the box in first column if the item is a Specialty Item as defined by the Special Provision in the contract

For Supplier or Hauler 2nd tier subcontracts, this section is not required.

|SPEC |Contract ID |LINE ITEM NUMBER |ITEM CODE |QUANTITY |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

| | | | | | |$ 0.00 |

| | | | | |

|TOTAL |$ 0.00 |

Instructions for completing Form DOT-485A:

1. Enter Contract ID number as shown on the Contract. It is in this format: B12345-00-000-0

Enter the original Contract Bid Amount. Enter the Date the contract was Let.

2. Enter the Project Number and County(ies). For multi-project contracts, if the subcontract is on only one project, enter only that one. If the subcontract is for multiple projects, enter the primary project number + “and others”.

3. Enter the Parent (or 1st tier) subcontract number in this format 001-0. Also, show the date that the Subcontract was executed between the Prime Contractor and the Subcontractor.

4. Indicate if the Parent subcontract is a Supplier or Hauler. Leave checkboxes blank if not.

5. Select the subcontract type, indicate if the Subcontractor is a certified D.B.E. or W.B.E. Also, indicate whether or not the Subcontractor is bonded to the Prime Contractor.

6. Enter the total parent Subcontract amount and percentage as shown on the approved DOT485.

7. Enter the 2nd Tier subcontract number in this format, 001-1, where 001-0 is the parent Subcontract number. These numbers should advance in sequential increments, i.e., 001-1, 001-2, 001-3. Enter the date of the agreement between the Parent and 2nd Tier Subcontractor.

8. Indicate if the 2nd tier subcontract is a Supplier or Hauler If the Parent subcontract is a supplier or hauler, the 2nd tier subcontract will fall in the same classification. If they are neither a supplier nor hauler, leave blank.

9. Enter the 2nd Tier Subcontractor’s full business name, Vendor ID No., and the City and State where they are located.

10. Select the subcontract type, indicate if the 2nd Tier Subcontractor is a certified D.B.E. or W.B.E. Also, indicate whether or not the 2nd Tier Subcontractor is bonded to the Prime Contractor.

11. Enter the name of the Parent subcontractor. Enter the name and title of the principal officer of the 2nd Tier Subcontractor.

12. Enter the total amount of this 2nd Tier Subcontract request. (The total amount of all executed and approved 2nd Tier Subcontracts, including this request, will calculate when the electronic form is printed if the File/Print/Options ‘Update Fields’ checkbox is on.).

13. List each previously approved 2nd Tier Subcontractor and the amount of each 2nd Tier Subcontract

14. Form DOT 485A must be signed by a principal officer of the Prime Contractor and the parent Subcontractor.

15. Indicate for each item if it is a Specialty Item as defined by the Special Provision in the Contract. List each item that is to be performed under this 2nd Tier Subcontract exactly as shown in the approved parent Subcontract, including Contract ID and Line Item Number. Show actual quantities, unit prices, and amounts agreed to by the Subcontractor and the 2nd Tier Subcontractor. (The Amount column total will calculate when the electronic form is printed if the File/Print/Options ‘Update Fields’ checkbox is on.)

16. If the 2nd Tier Subcontractor is to perform a portion of an item, an explanation will be required as to how the total amount for that item was arrived at. For example, if a 2nd Tier Subcontractor is to perform only the clearing of the Clearing and Grubbing item and this represents 30% of the total amount bid for that item, this should be shown prior to arriving at the total amount of this Subcontract.

17. As stated in the Standard Specifications, the purchase of materials by the Prime Contractor for use by the Subcontractor will not be allowed when computing the 30% limitation (70% limitation for minor widening and resurfacing projects.)

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