GSP TDOT Utility Presentation - [PDF Document] (2024)

GSP TDOT Utility Presentation - [PDF Document] (1)

Tennessee Department of Transportation

Utility Relocation Requirements

Rick Yeager, Presenter

GSP TDOT Utility Presentation - [PDF Document] (2)

1

STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION NASHVILLE, TN 37243-0360

JOHN C. SCHROER BILL HASLAM COMMISSIONER GOVERNOR

Engineering Authorization Date: 5/24/2011 Federal Funds: 3/15/2011

JOE SHAW

TENNESSEE DEPARTMENT OF TRANSPORTATION Power

SUITE 600, JAMES K. POLK BUILDING

NASHVILLE, TN 37243

Project Eligible For

PROJECT#/S: XXXXX-XXXX-XX COUNTY/S: WILSON Chapter 86

FEDERAL: XX-XXX-XXX(XX) PIN #: 123456.00 Reimbursem*nt:

DESCRIPTION: SAMPLE ROADWAY PROJECT YES X NO

Please refer to the above captioned project number on all correspondence concerning utility relocation.

Dear Mr. Joe Shaw,

This letter will serve as authority for the Utility to proceed with ALL engineering that is necessary to prepare plans, schedule of working days, and estimates of cost for the adjustment of your facilities which may be in conflict with this project. This is done in accordance with the provisions of TCA 54-5-854.

If a consultant is needed, see paragraph “A” on page 2. Consultant package must be submitted and approved by this office before consultant engineering will be eligible for reimbursem*nt.

Estimates of cost prepared in response to this authorization are confidential and shall not be released or made available to anyone other than the Utility, the approved consultant, and TDOT.

Reimbursem*nt will be in accordance with TCA 54-5-804 and as amended by Public Chapter No. 86 of the Public Acts of 2003. The cost of any work done prior to the authorization date of this letter will not be eligible for reimbursem*nt.

This notice is not to be construed as authority to actually relocate any of your facilities. Any relocation work done prior to written approval from the State Utility Coordinator will not be eligible for reimbursem*nt.

This project is currently scheduled for letting: 06/12/2012

To be eligible for reimbursem*nt, if the project is qualified for Chapter 86 reimbursem*nt as noted above, the Utility MUST submit to this office for Location Approval by the revised due date (A): 10/14/2011

1) (5) half-sized, color coded relocation plans.

2) Completed TDOT Form 2004-16, including signed Schedule of Working Days and Chapter 86 Eligibility.

3) Utility declaration for reimbursem*nt.

In addition, to be eligible for inclusion of the utility relocation work in the State Construction contract, the following must be submitted by due date (B): 04/01/2012

1) PDF files of detailed Utility relocation plans.

2) PDF file of detailed Utility Specifications.

3) Completed Utility Item Spreadsheet in Excel format, including estimated construction costs.

4) Completed Utility individual permit sketches, if required.

The following will be provided to assist you in responding to the Department request:

SAMPLE

TDOT Cover Letter for Utility Relocation

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Consultant Engineering Approval Requirements

If a Utility wishes to use a Consultant for engineering services, the following information must be submitted to TDOT for approval before work can begin to prepare any submittals for relocation on a project.

The information that needs to be submitted to TDOT for approval of a Consultant is as follows:

• Certification of Consultant and Memorandum of Understanding (TDOT Form 2011-13)

• Letter from Utility requesting approval of Consulting services

• Estimate of Engineering Cost (TDOT Form 2013-16, page 1.1, shown on later slides)

• Consultant Scope of Work

• If a consultant is requesting Engineering fees based on a “continuing contract”, then a copy of the Continuing Contract between Utility and Consultant must be used.

GSP TDOT Utility Presentation - [PDF Document] (4)

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Consultant Engineering Approval Requirements

Reimbursem*nt for Fees

** Any work done by a Consultant Engineer prior to written approval from TDOT will NOT be eligible for reimbursem*nt.

** Reimbursem*nt will be limited to the Engineering Estimate of Cost maximum ceiling amount. If the Engineer finds that it is necessary to increase their fees, the Utility shall make a written request to the State for the fee increase, along with reasoning for the overrun, which will have to be approved by TDOT prior to incurring any additional costs. No increase shall be binding upon the State unless written prior approval is given by the State.

GSP TDOT Utility Presentation - [PDF Document] (5)

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CAD File Access Requirements

Utility or Consultant must fill out a CADD Files Disclaimer (TDOT Form 2011-14) in order to gain access to the electronic utility relocation files from TDOT.

Once the form has been submitted and received by TDOT, then they will release access to the electronic files for use by the Utility or Consultant.

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Rainbow Plans

GSP TDOT Utility Presentation - [PDF Document] (7)

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“A” Date Submittal Requirements

When a Utility or Consultant is submitting an “A” date package for relocation, the submittal needs to consist of the following:

• (1) set of color-coded Utility Marked Relocation Plans in pdf format

» red-new » green-remove » orange-existing to remain » blue-temporary

• Utility Engineering and Relocation Estimate (TDOT Form 2013-16, shown on later slides)

• Declaration of Scheduled Calendar Days (TDOT Form 2013-16, page 6.1, shown on later slides)

• Utility “Declaration for Reimbursem*nt” letter

GSP TDOT Utility Presentation - [PDF Document] (8)

7

“B” Date Submittal Requirements

When a Utility or Consultant is submitting a “B” date package for relocation, the submittal needs to consist of the following:

• (1) Printed copy of completed Master Consultant Excel Spreadsheet (MCES) (including Item Numbers, Descriptions, Units, and Per Unit Labor and Material Costs)

• (1) Electronic copy of detailed Relocation Plans stamped and signed (Black and White) (pdf format)

• (1) Electronic copy of color-coded relocation plans (pdf format)

• (1) Electronic copy of Construction Specifications (pdf format)

• (1) Electronic copy of Master Consultant Excel Spreadsheet (MCES) (Excel format)

• (1) Electronic copy of CAD files of utility relocation (dgn format)

• All electronic files are to be burned to a CD and submitted along with the printed copies of the required materials.

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TDOT Form 2013-16 (Utility Engineering and Relocation Estimate)

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TDOT Form 2013-16

The TDOT Form 2013-16 for Utility Relocation can be very over-whelming at first glance.

The 2013-16 Form is made up of (10) different pages, and is filled out in Excel format. These pages are filled out and submitted to TDOT as part of the “A” date package for Utility Relocation. The sheets are labeled as follows:

Cover Sheet- Project, Utility and Consultant InformationSheet 1.1 - Estimate of Engineering Cost

(Consultant and In-House)Sheet 2.1 - Labor, Materials, Salvage and Betterment

(Installation and Removal)Sheet 3.1 - Easem*nt Acquisition and Inspection CostsSheet 4.1 - Utility Relocation Estimate SummarySheet 4.2 - Chapter 86 CertificationSheet 5.1 - Move Prior Certification ObligationSheet 5.2 - Certification ExceptionsSheet 6.1 - Declaration of Scheduled Calendar DaysSheet 6.2 - Maintenance of Traffic Procedures

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TDOT Form 2013-16

How to submit TDOT Form 2013-16

This form must be completed in its entirety and submitted along with one full-size pdf set of color-coded plans to satisfy the “A” date submittal for TDOT to be considered for Chapter 86 Reimbursem*nt (if applicable).

The form is “protected”, so please do not attempt to “unpro-tect” the spreadsheet when filling out the required information.

If there are any questions concerning the information required in the spreadsheet, please contact the TDOT Utility Representative for the region in which the project is located (found on the Utility’s Notification letter for project).

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Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

All information on the Cover Sheet is to be filled out by the Utility and/or Consultant.

Please be sure to complete this sheet in it’s entirety as the information that is entered will carry through the entire 2013-16 Workbook.

Cover Sheet

Utility Name:

Utility Address:

City, State: Zip Code:

Phone:

Contact Name:

Email:

Consultant Name:

Consultant Address:

Zip Code:

Phone:

Contact Name:

Email:

Project Description:

Federal Project No.:

State Project No.:

County(ies):

October 2013

TDOT PROJECT INFORMATION

CONSULTANT INFORMATION

UTILITY ENGINEERING AND RELOCATION

ESTIMATE

UTILITY INFORMATION

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Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

Consultant Estimate of Engineering Cost can be filled out one of two ways, using either Standard Consulting or Continuing Contract. If there is no continuing contract between the Utility and the Consultant for Engineering services, check the “standard contract” box. If using a consultant that has an existing continuing contract, then check the “continuing contract” box.

The same information applies that is in the In-House Estimate of Engineering Cost, for the exception of a line item for Profit. Therefore, the completion of both forms are very similar.

Estimate of Engineering Cost

TDOT Project Number(s):

Utility Name & Address: Consultant Name & Address:

Place an "X" in the appropriate box: Standard Contract Continuing Contract (attach copy of Contract for TDOT verification)

I. ENGINEERING SERVICES

Classification Rate/Hr Hours Total Hours Total Hours Total

Principal -$ -$ -$ -$

Project Manager -$ -$ -$ -$

Design Engineer -$ -$ -$ -$

Designer / Senior Designer -$ -$ -$ -$

Techician / Draftsperson -$ -$ -$ -$

Administrative -$ -$ -$ -$

Field Inspector -$ -$ -$ -$

Licensed Surveyor -$ -$ -$ -$

Rod Person -$ -$ -$ -$

-$ -$ -$ -$

0 -$ 0 -$ 0 -$

II. REIMBURSABLE EXPENSES

Cost/Unit Quantity Total Quantity Total Quantity Total

Transportation / Mile: 0.47$ X = -$ -$ = -$

Meals / Day: -$ X = -$ -$ = -$

Lodging / Day: -$ X = -$ -$ = -$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses -$ -$ -$

Indirect/Overhead Rate (not to exceed 145%): 0.00% -$ 0.00% -$ 0.00% -$

Allowable Rate (Maximum of 13%): 0.00% -$ 0.00% -$ 0.00% -$

TOTAL ENGINEERING / SURVEY COST:

Standard Consultant: (I+II+III+IV) = -$ Private: -$ Private: -$

Continuing Contract: (I+II) = -$ Public: -$ Public: -$

Standard Consultant: -$

Continuing Contract: -$

I. ENGINEERING SERVICES

Classification Rate/Hr Hours Total Hours Total Hours Total

Project Manager -$ -$ -$ -$

Engineer -$ -$ -$ -$

Draftperson -$ -$ -$ -$

Administrative -$ -$ -$ -$

Field Inspector -$ -$ -$ -$

Licensed Surveyor -$ -$ -$ -$

Rod Person -$ -$ -$ -$

-$ -$ -$ -$

0 -$ 0 -$ 0 -$

II. REIMBURSABLE EXPENSES

Cost/Unit Quantity Total Quantity Total Quantity Total

Transportation / Mile: 0.47$ X = -$ -$ = -$

Meals / Day: -$ X = -$ -$ = -$

Lodging / Day: -$ X = -$ -$ = -$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses -$ -$ -$

Indirect/Overhead Rate (not to exceed 145%): 0.00% -$ 0.00% -$ 0.00% -$

-$ Private: -$

Public: -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 1.1

0 0

TOTAL ENGINEERING COST: TOTAL INSPECTION COST:

ESTIMATE OF ENGINEERING COST

CONSULTANT ENGINEERING ESTIMATE

IN-HOUSE ENGINEERING ESTIMATE

III. INDIRECT / OVERHEAD EXPENSES

PRE-CONSTRUCTION/CONSTRUCTION FIELD SURVEYING CONSTRUCTION INSPECTION

Total Engineering Services

County(ies):

TOTAL COST (Engineering and Inspection)

(Expenses for Sections III and IV only apply to Consultant Engineering Services without a Continuing Contract agreement with the Utility)

INSPECTION (Standard) INSPECTION (Continuing)

Total Engineering Services

CONSTRUCTION INSPECTIONFIELD SURVEYINGPRE-CONSTRUCTION/CONSRUCTION

IV. PROFIT: (2.35x(1,2,3)x ALLOWABLE RATE)

III. INDIRECT / OVERHEAD EXPENSES

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TDOT Project Number(s):

Utility Name & Address:

Consultant Name & Address:

Place an "X" in the appropriate box:Standard Contract

Continuing Contract (attach copy of Contract for TDOT verification)

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Principal

-$

-$

-$

-$

Project Manager

-$

-$

-$

-$

Design Engineer

-$

-$

-$

-$

Designer / Senior Designer-

$

-$

-$

-$

Techician / Draftsperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

Allowable Rate (Maximum of 13%):

0.00%

-$

0.00%

-$

0.00%

-$

TOTAL ENGINEERING / SURVEY COST:

Standard Consultant: (I+II+III+IV) =

-$

Private:

-$

Private:

-$

Continuing Contract: (I+II) =

-$

Public:

-$

Public:

-$

Standard Consultant:

-$

Continuing Contract:

-$

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Project Manager

-$

-$

-$

-$

Engineer

-$

-$

-$

-$

Draftperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

-$

Private:

-$

Public:-

$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 1.1

TOTAL ENGINEERING COST:TOTAL INSPECTION COST:

ESTIMATE OF ENGINEERING COST

CONSULTANT ENGINEERING ESTIMATE

IN-HOUSE ENGINEERING ESTIMATE

III. INDIRECT / OVERHEAD EXPENSES

PRE-CONSTRUCTION/CONSTRUCTIONFIELD SURVEYING

CONSTRUCTION INSPECTION

Total Engineering Services

County(ies):

TOTAL COST (Engineering and Inspection)(Expenses for Sections III and IV only apply to Consultant Engineering Services without a Continuing Contract agreement with the Utility)

INSPECTION (Standard)INSPECTION (Continuing)

Total Engineering Services

CONSTRUCTION INSPECTION

FIELD SURVEYING

PRE-CONSTRUCTION/CONSRUCTION

IV. PROFIT: (2.35x(1,2,3)x ALLOWABLE RATE)

III. INDIRECT / OVERHEAD EXPENSES

Engineering: Include rate and hours for the positions that will be utilized for the project in Area I (if applicable). Pre-Construction Engineering will be any engineering needed PRIOR to the letting. Construction Engineering will be any engineering potentially needed during the construction of the project.

Surveying: Most survey work is done by TDOT. If there will be additional surveying needed for relocation, input that information.

Construction Inspection:Include hours that will be required to provide a Resident Project Representative on-site during construction as required by TDOT.

Estimate of Engineering Cost Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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TDOT Project Number(s):

Utility Name & Address:

Consultant Name & Address:

Place an "X" in the appropriate box:Standard Contract

Continuing Contract (attach copy of Contract for TDOT verification)

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Principal

-$

-$

-$

-$

Project Manager

-$

-$

-$

-$

Design Engineer

-$

-$

-$

-$

Designer / Senior Designer-

$

-$

-$

-$

Techician / Draftsperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

Allowable Rate (Maximum of 13%):

0.00%

-$

0.00%

-$

0.00%

-$

TOTAL ENGINEERING / SURVEY COST:

Standard Consultant: (I+II+III+IV) =

-$

Private:

-$

Private:

-$

Continuing Contract: (I+II) =

-$

Public:

-$

Public:

-$

Standard Consultant:

-$

Continuing Contract:

-$

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Project Manager

-$

-$

-$

-$

Engineer

-$

-$

-$

-$

Draftperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

-$

Private:

-$

Public:-

$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 1.1

TOTAL ENGINEERING COST:TOTAL INSPECTION COST:

ESTIMATE OF ENGINEERING COST

CONSULTANT ENGINEERING ESTIMATE

IN-HOUSE ENGINEERING ESTIMATE

III. INDIRECT / OVERHEAD EXPENSES

PRE-CONSTRUCTION/CONSTRUCTIONFIELD SURVEYING

CONSTRUCTION INSPECTION

Total Engineering Services

County(ies):

TOTAL COST (Engineering and Inspection)(Expenses for Sections III and IV only apply to Consultant Engineering Services without a Continuing Contract agreement with the Utility)

INSPECTION (Standard)INSPECTION (Continuing)

Total Engineering Services

CONSTRUCTION INSPECTION

FIELD SURVEYING

PRE-CONSTRUCTION/CONSRUCTION

IV. PROFIT: (2.35x(1,2,3)x ALLOWABLE RATE)

III. INDIRECT / OVERHEAD EXPENSES

Other Expenses: List all other expenses in this area. TDOT has standard “reim-bursable rates” for mileage and lodging, so check with them before assigning an amount in these areas. If listing an expense next to “Other”, please include a description of this expense or it may not be approved for reimbursem*nt.

Indirect/Overhead Expenses: The appropriate rate should be calculated internally.

Total Engineering Cost: The total engineering cost will fill itself out based on the infor-mation provided in areas I through IV of the sheet, no input is necessary in this section.

Estimate of Engineering Cost Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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TDOT Project Number(s):

Utility Name & Address:

Consultant Name & Address:

Place an "X" in the appropriate box:Standard Contract

Continuing Contract (attach copy of Contract for TDOT verification)

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Principal

-$

-$

-$

-$

Project Manager

-$

-$

-$

-$

Design Engineer

-$

-$

-$

-$

Designer / Senior Designer-

$

-$

-$

-$

Techician / Draftsperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

Allowable Rate (Maximum of 13%):

0.00%

-$

0.00%

-$

0.00%

-$

TOTAL ENGINEERING / SURVEY COST:

Standard Consultant: (I+II+III+IV) =

-$

Private:

-$

Private:

-$

Continuing Contract: (I+II) =

-$

Public:

-$

Public:

-$

Standard Consultant:

-$

Continuing Contract:

-$

I. ENGINEERING SERVICES

ClassificationRate/Hr

HoursTotal

HoursTotal

HoursTotal

Project Manager

-$

-$

-$

-$

Engineer

-$

-$

-$

-$

Draftperson

-$

-$

-$

-$

Administrative

-$

-$

-$

-$

Field Inspector

-$

-$

-$

-$

Licensed Surveyor

-$

-$

-$

-$

Rod Person

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

II. REIMBURSABLE EXPENSESCost/Unit

QuantityTotal

QuantityTotal

QuantityTotal

Transportation / Mile:

0.47$

X=

-$

-$

=-

$

Meals / Day:

-$

X=

-$

-$

=-

$

Lodging / Day:

-$

X=

-$

-$

=-

$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses

-$

-$

-$

Indirect/Overhead Rate (not to exceed 145%):0.00%

-$

0.00%

-$

0.00%

-$

-$

Private:

-$

Public:-

$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 1.1

TOTAL ENGINEERING COST:TOTAL INSPECTION COST:

ESTIMATE OF ENGINEERING COST

CONSULTANT ENGINEERING ESTIMATE

IN-HOUSE ENGINEERING ESTIMATE

III. INDIRECT / OVERHEAD EXPENSES

PRE-CONSTRUCTION/CONSTRUCTIONFIELD SURVEYING

CONSTRUCTION INSPECTION

Total Engineering Services

County(ies):

TOTAL COST (Engineering and Inspection)(Expenses for Sections III and IV only apply to Consultant Engineering Services without a Continuing Contract agreement with the Utility)

INSPECTION (Standard)INSPECTION (Continuing)

Total Engineering Services

CONSTRUCTION INSPECTION

FIELD SURVEYING

PRE-CONSTRUCTION/CONSRUCTION

IV. PROFIT: (2.35x(1,2,3)x ALLOWABLE RATE)

III. INDIRECT / OVERHEAD EXPENSES

Total Inspection Cost: Inspection costs are reimbursed on a “private/public” percent-ages. Utilities will only be reimbursed for inspection services for areas of their facilities that are currently on Private ROW. The Total Inspection Cost cells will not be filled in until the percentage of Private and Public are calculated on Sheet 4.1.

Estimate of Engineering Cost Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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Labor, Materials, Salvage and Betterment Removal - Labor, Materials and Salvage Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No. Item Description Qty Unit Cost Extended Unit Cost Extended

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

TOTAL INSTALLATION COSTS -$ -$ -$ -$ -$ -$

TDOT Item No. Item Description Qty Unit Cost Extended Unit Cost Extended Clearing & Grubbing: -$

-$ -$ Traffic Control: -$

-$ -$ Erosion Control: -$

-$ -$

-$ -$ TOTAL SITE COST -$

-$ -$ -$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

TOTAL REMOVAL COSTS -$ -$ -$ -$ -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS

(Move Prior Only)

Labor Material

BETTERMENT

SITE COSTS

LABOR

In House Cost Contract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / Reused

Contract (Bid/Continuing) Junked /

Scrapped

Removal of Labor and Materials should reflect an “estimated” value for the removal of the existing facilities on the project.

Items are to be listed according to the Standard Utility Item Numbers as provided by TDOT. The Standard Utility Item Numbers can be found on TDOT’s website.

GSP TDOT Utility Presentation - [PDF Document] (18)

17

EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

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-$

-$

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-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL INSTALLATION COSTS

-$

-$

-$

-

$

-$

-

$

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

Clearing & Grubbing: -

$

-$

-$

Traffic Control: -

$

-$

-$

Erosion Control: -

$

-$

-$

-$

-$

TOTAL SITE COST -

$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL REMOVAL COSTS

-$

-$

-

$

-$

-$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS(Move Prior Only)

LaborMaterial

BETTERMENT

SITE COSTS

LABOR

In House CostContract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / ReusedContract (Bid/Continuing)

Junked /

Scrapped

Labor, Materials, Salvage and Betterment Removal - Labor, Materials and Salvage

Labor: Labor Unit Prices should include all equipment needed to remove the facilities for the project.

If the relocation is being done “prior to” the letting, the units can be listed under either “In House” or “Continuing”. If the relocation is being done as part of the roadway contract, then the unit will be listed under “Bid Contract”.

Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

GSP TDOT Utility Presentation - [PDF Document] (19)

18

EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

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-$

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-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL INSTALLATION COSTS

-$

-$

-$

-

$

-$

-

$

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

Clearing & Grubbing: -

$

-$

-$

Traffic Control: -

$

-$

-$

Erosion Control: -

$

-$

-$

-$

-$

TOTAL SITE COST -

$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL REMOVAL COSTS

-$

-$

-

$

-$

-$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS(Move Prior Only)

LaborMaterial

BETTERMENT

SITE COSTS

LABOR

In House CostContract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / ReusedContract (Bid/Continuing)

Junked /

Scrapped

Material: Material Unit prices should include all existing material on the unit that is being listed.

Salvage Material: Any materials that are going to be salvaged from the Utility need to be assigned a value. TDOT will not reimburse a util-ity for materials that can be re-used by the utility for their facilities.

Labor, Materials, Salvage and Betterment Removal - Labor, Materials and Salvage Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

GSP TDOT Utility Presentation - [PDF Document] (20)

19

EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

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-$

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-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL INSTALLATION COSTS

-$

-$

-$

-

$

-$

-

$

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

Clearing & Grubbing: -

$

-$

-$

Traffic Control: -

$

-$

-$

Erosion Control: -

$

-$

-$

-$

-$

TOTAL SITE COST -

$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL REMOVAL COSTS

-$

-$

-

$

-$

-$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS(Move Prior Only)

LaborMaterial

BETTERMENT

SITE COSTS

LABOR

In House CostContract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / ReusedContract (Bid/Continuing)

Junked /

Scrapped

Installation Labor and Materials should reflect an “estimated” value for the installation of the new facilities that will be required on the project.

Remember: Note whether equipment is being listed separately and not being included in the installation labor unit pricing, or if it is to be included in the unit price for installation, by check-ing the appropriate box in the upper left corner of the sheet.

Material: Material Unit prices should include all materials necessary to install the unit that is being listed in it’s entirety. If a utility is providing some or all of the materials, list those costs under “provided to state”.

Installation - Labor, Material and Betterment Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

GSP TDOT Utility Presentation - [PDF Document] (21)

20

EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

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-$

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-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL INSTALLATION COSTS

-$

-$

-$

-

$

-$

-

$

TDOT Item No.Item Description

Qty Unit Cost Extended Unit Cost Extended

Clearing & Grubbing: -

$

-$

-$

Traffic Control: -

$

-$

-$

Erosion Control: -

$

-$

-$

-$

-$

TOTAL SITE COST -

$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

-$

TOTAL REMOVAL COSTS

-$

-$

-

$

-$

-$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS(Move Prior Only)

LaborMaterial

BETTERMENT

SITE COSTS

LABOR

In House CostContract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / ReusedContract (Bid/Continuing)

Junked /

Scrapped

Betterment: If a utility is considering “upgrading” their existing facilities, the difference in what is existing on their facilities versus what they want to install is considered “betterment”. The values for this difference (in both labor and material costs) need to be noted in the Betterment column of the sheet. TDOT will reimburse utilities for “in kind” replacement of their facilities. Anything that the utility wished to install that will improve their system will need to be listed as betterment.

Installation - Labor, Material and Betterment Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

GSP TDOT Utility Presentation - [PDF Document] (22)

21

Replacement Easem*nt Acquisition: For areas of relocation that fall outside public ROW, the utility is required to acquire the ROW necessary to relocate their facilities. In order for the utility to get reimbursed for these purchases, the information in this section needs to be filled out.

Easem*nt Acquisition and Inspection CostsCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

EXISTING

EAsem*nT (SF)

PROPOSED

EAsem*nT (SF)

SURVEY &

ENGINEERING COSTATTORNEYS FEES

RECORDING &

OFFICE COSTEAsem*nT COST

SHEET SUBTOTAL

COST

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

Total Easem*nt Acquisition Expenses TOTAL -$

STANDARD CONTINUING STANDARD CONTINUING

$ - $ - -$ -$ -$

-$ -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 3.1

NO - the utility will not seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

YES - the utility will seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

-$

Replacement Easem*nt Acquisition Expenses

INSPECTION COSTS (PUBLIC)

CONSULTANTIN-HOUSE IN-HOUSE

Attached Additional Sheets: Y / N

SHEET NUMBER

CONSULTANT

INSPECTION COSTS (PRIVATE)

GSP TDOT Utility Presentation - [PDF Document] (23)

22

EXISTING

EAsem*nT (SF)

PROPOSED

EAsem*nT (SF)

SURVEY &

ENGINEERING COSTATTORNEYS FEES

RECORDING &

OFFICE COSTEAsem*nT COST

SHEET SUBTOTAL

COST

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

-$

-

$

-$

-

$

-$

Total Easem*nt Acquisition Expenses

TOTAL

-$

STANDARD CONTINUING

STANDARDCONTINUING

$ - $

-

-$

-

$

-$

-$

-$

Revision 10-25-2013

TDOT Utility Form 2013-16

Sheet 3.1

NO - the utility will not seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

YES - the utility will seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

-$

Replacement Easem*nt Acquisition Expenses

INSPECTION COSTS (PUBLIC)

CONSULTANT

IN-HOUSE

IN-HOUSE

Attached Additional Sheets: Y / N

SHEET NUMBER

CONSULTANTINSPECTION COSTS (PRIVATE)

Inspection Cost: The costs associated with Inspection Services will be calculated from Sheet 1.1. However, the utility will need to check the appro-priate box on whether or not they are seeking reimbursem*nt for any eligible inspection expenses.

Inspection Costs on PRIVATE ROW are reimbursable under Chapter 86, so Utilities need to ensure that they pay close attention to whether or not their existing facilities fall on existing PRIVATE ROW.

Easem*nt Acquisition and Inspection CostsCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

GSP TDOT Utility Presentation - [PDF Document] (24)

23

The Utility Relocation Estimate Summary, will be filled in as the first (4) sheets of the spreadsheet are completed. However, there are additional areas of this sheet that will need to be completed.

Contact Information: Contact information listed here will be automatically filled in with the information provided on the Cover Sheet.

Utility Relocation Estimate SummaryCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

Project No:

County:

Date:

Primary Contact:

E-mail: Phone:

Secondary Contact: RG Approval and Date:

E-mail: Phone:

Utility Name: Consult Appr. Date: / /

Address: Amount Approved: -$

City, State: Zip: 0 HQ Approval and Date:

Percent On Private: 0% Private ROW - #Poles / Length of facility: CH86 Y / N PIN#:

Percent On Public: 0% Public ROW - #Poles / Length of facility: LET: / / Contract #:

Total Percentage: 0% Total #Poles / Length of facility: 0 Easem*nt Contract #

N

REIMBURsem*nT MOVE PRIOR % Private / Public Relocation

REQUESTED MOVE IN State Contract % Private / Public MOVE IN State Contract

(Please check ONE) Other Utility Replacement Easem*nt Reimbursem*nt

Amount

Pre-Construction / Construction -$ -$

-$

-$ -$

-$

-$

-$

-$

Amount N

-$ Y

-$

-$

-$

-$

-$ RELOCATION EXCEEDS $1.75M CAP: -$

-$

AMOUNT OVER 75% REIMBURsem*nT: -$

-$

Amount

-$ CHAPTER 86 MOVE-IN CONTRACT: -$

-$

NON-CHAPTER 86 MOVE-IN CONTRACT: -$

-$

-$

ESTIMATED TOTAL CONSTRUCTION COST: $ -

Revision 10-25-2013 TDOT Utility Form 2013-16

Page 4.1

UTLITY DEPOSIT (IF APPLICABLE)

ENGINEERING COST:

Description

BETTERMENT

ESTIMATED CONSTRUCTION COST:

Does Estimate Exceed $1.75M Cap? -

Does Estimate Require 75% Cap? -

CHAPTER 86 MOVE PRIOR:

NON-CHAPTER 86 MOVE-IN CONTRACT:

NON-CHAPTER 86 MOVE PRIOR:

CONSTRUCTION (LABOR & MATERIAL)

January 27, 2014

Description

NO COST / NO REIMBURsem*nT (STOP HERE, REMAINDER OF FORM IS NOT REQUIRED)

TDOT USE ONLY

Is Utility Chapter 86 Certified (Obtained from Certification Sheet)?

(If project does not qualify for Chapter 86 Reimbursem*nt, then "Percent on Private" will be used to calculate total amount due to Utility)

NON-CHAPTER 86CHAPTER 86

ENGINEERING

Installation Materials

Removal Labor

Site Costs

Material Provided to State

Salvage Materials

Non-Usable Materials

**Submittal and completion of this form is required for consideration of reimbursem*nt on this project.**

Field Surveying

Construction Inspection

Reimbursable Expenses

Installation Labor

UTILITY REIMBURsem*nT

CHAPTER 86 MOVE-IN CONTRACT:

If cost is listed above, separate Easem*nt Contract is needed

AMOUNT TO BE PAID BY THE UTILITY

Installation Labor

Installation Materials

Description

The Utility will reference the page number where designated on the form when other Detail Cost Estimate sheets are attached.

ESTIMATED UTILITY BETTERMENT COST:

ESTIMATED REPLACEMENT EAsem*nT COST:

GSP TDOT Utility Presentation - [PDF Document] (25)

24

Project No:

County:

Date:

Primary Contact:

E-mail:

Phone:

Secondary Contact:

RG Approval and Date:

E-mail:

Phone:

Utility Name:

Consult Appr. Date: / /

Address:

Amount Approved:-

$

City, State:

Zip:0

HQ Approval and Date:

Percent On Private: 0%Private ROW - #Poles / Length of facility:

CH86 Y / N PIN#:

Percent On Public: 0%Public ROW - #Poles / Length of facility:

LET: / / Contract #:

Total Percentage:0%

Total #Poles / Length of facility:0 Easem*nt Contract #

N

REIMBURsem*nTMOVE PRIOR

% Private / Public Relocation

REQUESTEDMOVE IN State Contract

% Private / Public MOVE IN State Contract

(Please check ONE) Other

Utility Replacement Easem*nt Reimbursem*nt

Amount

Pre-Construction / Construction

-$

-$

-$

-$

-$

-$

-$

-$

-$

Amount

N

-$

Y

-$

-$

-$

-$

-$

RELOCATION EXCEEDS $1.75M CAP:

-$

-$

AMOUNT OVER 75% REIMBURsem*nT:

-$

-$

Amount

-$

CHAPTER 86 MOVE-IN CONTRACT:

-$

-$

NON-CHAPTER 86 MOVE-IN CONTRACT:

-$

-$

-$

ESTIMATED TOTAL CONSTRUCTION COST: $ -

Revision 10-25-2013

TDOT Utility Form 2013-16

Page 4.1

UTLITY DEPOSIT (IF APPLICABLE)

ENGINEERING COST:

Description

BETTERMENTESTIMATED CONSTRUCTION COST:

Does Estimate Exceed $1.75M Cap? -

Does Estimate Require 75% Cap? -

CHAPTER 86 MOVE PRIOR:

NON-CHAPTER 86 MOVE-IN CONTRACT:

NON-CHAPTER 86 MOVE PRIOR:

CONSTRUCTION (LABOR & MATERIAL)

January 27, 2014

Description

NO COST / NO REIMBURsem*nT (STOP HERE, REMAINDER OF FORM IS NOT REQUIRED)

TDOT USE ONLY

Is Utility Chapter 86 Certified (Obtained from Certification Sheet)?

(If project does not qualify for Chapter 86 Reimbursem*nt, then "Percent on Private" will be used to calculate total amount due to Utility)

NON-CHAPTER 86

CHAPTER 86

ENGINEERING

Installation Materials

Removal Labor

Site Costs

Material Provided to State

Salvage Materials

Non-Usable Materials

**Submittal and completion of this form is required for consideration of reimbursem*nt on this project.**

Field Surveying

Construction Inspection

Reimbursable Expenses

Installation Labor

UTILITY REIMBURsem*nT

CHAPTER 86 MOVE-IN CONTRACT:

If cost is listed above, separate Easem*nt Contract is needed

AMOUNT TO BE PAID BY THE UTILITY

Installation Labor

Installation Materials

Description

The Utility will reference the page number where designated on the form when other Detail Cost Estimate sheets are attached.

ESTIMATED UTILITY BETTERMENT COST:

ESTIMATED REPLACEMENT EAsem*nT COST:

Percentage Information: The cells that list the percentages of the facility on Private and Public are automatically calculated by the number of poles/length of facility information. Only the cells showing the Private ROW & Public ROW - # Main Poles/Length facil-ity need to be filled out. DO NOT input the percentages directly on the sheet.

No Cost/No Reimbursem*nt: If a Utility is relocating their facilities at no cost to the state, then check this box.

Utility Requests Reimbursem*nt: Check the appropriate box for the reimbursem*nt that is being requested on the project.

All other fields of this sheet will be filled in automatically when the appropriate box is checked for which type of reimburse-ment is being requested by the utility.

Utility Relocation Estimate SummaryCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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Project No:

County:

Date:

Primary Contact:

E-mail:

Phone:

Secondary Contact:

RG Approval and Date:

E-mail:

Phone:

Utility Name:

Consult Appr. Date: / /

Address:

Amount Approved:-

$

City, State:

Zip:0

HQ Approval and Date:

Percent On Private: 0%Private ROW - #Poles / Length of facility:

CH86 Y / N PIN#:

Percent On Public: 0%Public ROW - #Poles / Length of facility:

LET: / / Contract #:

Total Percentage:0%

Total #Poles / Length of facility:0 Easem*nt Contract #

N

REIMBURsem*nTMOVE PRIOR

% Private / Public Relocation

REQUESTEDMOVE IN State Contract

% Private / Public MOVE IN State Contract

(Please check ONE) Other

Utility Replacement Easem*nt Reimbursem*nt

Amount

Pre-Construction / Construction

-$

-$

-$

-$

-$

-$

-$

-$

-$

Amount

N

-$

Y

-$

-$

-$

-$

-$

RELOCATION EXCEEDS $1.75M CAP:

-$

-$

AMOUNT OVER 75% REIMBURsem*nT:

-$

-$

Amount

-$

CHAPTER 86 MOVE-IN CONTRACT:

-$

-$

NON-CHAPTER 86 MOVE-IN CONTRACT:

-$

-$

-$

ESTIMATED TOTAL CONSTRUCTION COST: $ -

Revision 10-25-2013

TDOT Utility Form 2013-16

Page 4.1

UTLITY DEPOSIT (IF APPLICABLE)

ENGINEERING COST:

Description

BETTERMENTESTIMATED CONSTRUCTION COST:

Does Estimate Exceed $1.75M Cap? -

Does Estimate Require 75% Cap? -

CHAPTER 86 MOVE PRIOR:

NON-CHAPTER 86 MOVE-IN CONTRACT:

NON-CHAPTER 86 MOVE PRIOR:

CONSTRUCTION (LABOR & MATERIAL)

January 27, 2014

Description

NO COST / NO REIMBURsem*nT (STOP HERE, REMAINDER OF FORM IS NOT REQUIRED)

TDOT USE ONLY

Is Utility Chapter 86 Certified (Obtained from Certification Sheet)?

(If project does not qualify for Chapter 86 Reimbursem*nt, then "Percent on Private" will be used to calculate total amount due to Utility)

NON-CHAPTER 86

CHAPTER 86

ENGINEERING

Installation Materials

Removal Labor

Site Costs

Material Provided to State

Salvage Materials

Non-Usable Materials

**Submittal and completion of this form is required for consideration of reimbursem*nt on this project.**

Field Surveying

Construction Inspection

Reimbursable Expenses

Installation Labor

UTILITY REIMBURsem*nT

CHAPTER 86 MOVE-IN CONTRACT:

If cost is listed above, separate Easem*nt Contract is needed

AMOUNT TO BE PAID BY THE UTILITY

Installation Labor

Installation Materials

Description

The Utility will reference the page number where designated on the form when other Detail Cost Estimate sheets are attached.

ESTIMATED UTILITY BETTERMENT COST:

ESTIMATED REPLACEMENT EAsem*nT COST:

Amount to be paid by the Utility: In 2007, restrictions were put in place concerning the reim-bursem*nt limitations for Chapter 86 relocation projects. These limitations were made effective for all projects that were issued after September 17, 2007, and they are as follows:

• Municipally Owned utilities, Utility Districts and Utility Cooperatives will be eligible for 100% reimbursem*nt up to $1.75 million of the relocation cost. Anything over $1.75 million will be paid entirely by the utility.

• All other utilities will be eligible for 75% reimbursem*nt up to $1.75 million of the relocation cost. Anything over $1.75 million will be paid entirely by the utility.

Utility Relocation Estimate SummaryCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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26

The Chapter 86 Certification page must be filled out and signed by the Utility requesting relocation reimbursem*nt.

Check the appropriate boxes that apply to the Utility that is request-ing reimbursem*nt. What the Utility is listed as in #4 (Municipally Owned, Utility District, Utility Cooperative) will determine if they fall within the 100% or 75% reimbursem*nt category for their relocation, which will determine how much (if any) additional funds need to be paid by the Utility to TDOT as a “deposit”.

Once the sheet is filled out, it must be signed and dated by the appropriate individual at the Utility requesting reimbursem*nt.

Chapter 86 CertificationCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

PROJECT #/S: COUNTY/S:

FEDERAL: PIN:

1. The utility is seeking reimbursem*nt under provisions of TCA 54-5-804 as ameneded by Public Acts 2003, Chapter number 86.

Water

Waste Water

Gas Distribution Transmission

Electric Distribution Transmission

Communication CATV Phone Fiberoptic Broadband

Street Lighting

Other

Signature: Date:

Print Name:

Title:

Utility Name:

Utility Address:

City, State, Zip:

Phone Number:

Fax Number:

Email Address:

Revision 10-25-2013 TDOT Utility Form 2013-16

Page 4.2

Municipally Owned Utility District Utility Cooperative

Chapter 86 Certification

5. The utility is considered to be a specific utility category listed in accordance with the Limitation provisions of the TDOT Policy 340-07:

4. The utility is eligible for reimbursem*nt in accordance with the Limitation provisions of the TDOT Policy 340-07 in that it is:

3. To the best of my knowledge the utility is in compliance with TCA 54-5-804(b) in that the utility has a valid permit to locate its utility

facility on the public highway right-of-way.

In accordance with Tennessee Department of Transportation policy number 340-07, the following information is provided

with regards to required compliance documentation for utility relocation reimbursem*nt in accordance with TCA 54-5-804

and TCA 54-5-854.

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

2. To the best of my knowledge the utility is in compliance with TCA § 54-5-804(a)(1) and this policy in that the utility has returned its

relocation plan, schedule, and cost estimate to the Department within 120 days after receipt of the Department’s project plans, or

within such additional time as may be allowed in accordance with TCA § 54-5-854(b).

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Chapter 86 Certification

PROJECT #/S:

COUNTY/S:

FEDERAL:

PIN:

1. The utility is seeking reimbursem*nt under provisions of TCA 54-5-804 as ameneded by Public Acts 2003, Chapter number 86.

Water

Waste Water

GasDistribution

Transmission

ElectricDistribution

Transmission

CommunicationCATV

PhoneFiberoptic

Broadband

Street Lighting

Other

Signature:

Date:

Print Name:

Title:

Utility Name:

Utility Address:

City, State, Zip:

Phone Number:

Fax Number:

Email Address:

Revision 10-25-2013

TDOT Utility Form 2013-16

Page 4.2

Municipally OwnedUtility District

Utility Cooperative

Chapter 86 Certification

5. The utility is considered to be a specific utility category listed in accordance with the Limitation provisions of the TDOT Policy 340-07:

4. The utility is eligible for reimbursem*nt in accordance with the Limitation provisions of the TDOT Policy 340-07 in that it is:

3. To the best of my knowledge the utility is in compliance with TCA 54-5-804(b) in that the utility has a valid permit to locate its utility

facility on the public highway right-of-way.

In accordance with Tennessee Department of Transportation policy number 340-07, the following information is provided

with regards to required compliance documentation for utility relocation reimbursem*nt in accordance with TCA 54-5-804

and TCA 54-5-854.

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

2. To the best of my knowledge the utility is in compliance with TCA § 54-5-804(a)(1) and this policy in that the utility has returned its

relocation plan, schedule, and cost estimate to the Department within 120 days after receipt of the Department’s project plans, or

within such additional time as may be allowed in accordance with TCA § 54-5-854(b). Note: If the Utility is using a consultant for Engineering Services, the consultant must have this form signed by the utility. They cannot sign this form as a representative of the utility.

Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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The Certification Contract Obligation does not need to be submitted to TDOT with the “A” date package. This sheet is to be used for utilities that are relocating their facilities “PRIOR TO” the letting date of the project.

Move Prior Certification ObligationCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

Date: TDOT Region Construction Office

(Region)

Attn: ,Project Engineer

Address:

(information is provided on the Utility Begin Work Authorization letter)

PROJECT #/S: COUNTY/S:

FEDERAL: PIN:

DESCRIPTION:

UTILITY CONTRACT #:

The Utility completed their utility relocation on (date of completion) in accordance with the approved relocation

plans for the above referenced project number prior to the date specified and in accordance with the executed contract referenced.

NOTE EXCEPTIONS:

Maintaining services to business and/or residences is attached.

Signed: Date:

Print Name:

Title:

Utility Name: Water Telephone

Address: Sewer CATV

City, State, Zip: Power Other:

Phone No: Gas

Fax No:

Email:

This Certification Letter is accepted.

This Certification Letter is accepted pending Final Verification by

project staking.

This Certification is not accepted. Reason:

Signed: Date:

CC: TDOT Construction Project File

TDOT Regional Utility Office

Revision 10-25-2013 TDOT Utility Form 2013-16

Page 5.1

TDOT Construction office representative

Certification Contract Obligation

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

TDOT USE ONLY:

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29

Date:

TDOT RegionConstruction Office

(Region)

Attn:

,Project Engineer

Address:

(information is provided on the Utility Begin Work Authorization letter)

PROJECT #/S:

COUNTY/S:

FEDERAL:

PIN:

DESCRIPTION:

UTILITY CONTRACT #:

The Utility completed their utility relocation on(date of completion) in accordance with the approved relocation

plans for the above referenced project number prior to the date specified and in accordance with the executed contract referenced.

NOTE EXCEPTIONS:

Maintaining services to business and/or residences is attached.

Signed:

Date:

Print Name:

Title:

Utility Name:

WaterTelephone

Address:

SewerCATV

City, State, Zip:

PowerOther:

Phone No:

Gas

Fax No:

Email:

This Certification Letter is accepted.

This Certification Letter is accepted pending Final Verification by

project staking.

This Certification is not accepted. Reason:

Signed:

Date:

CC: TDOT Construction Project File

TDOT Regional Utility Office

Revision 10-25-2013

TDOT Utility Form 2013-16

Page 5.1

TDOT Construction office representative

Certification Contract Obligation

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

TDOT USE ONLY:

If a utility decides to relocate their facilities prior to the letting, they will be responsible for the following:

• Easem*nts needed if proposed ROW has not been acquired

• Providing environmental permits

• Coordination of the relocation of their facilities

• Construction of the relocation

• Providing Erosion Control

• Providing all necessary clearing and grubbing

• Disposal of waste

• Providing Traffic Control

• Provide any surveying necessary to complete the relocation

Move Prior Certification ObligationCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

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Date:

TDOT RegionConstruction Office

(Region)

Attn:

,Project Engineer

Address:

(information is provided on the Utility Begin Work Authorization letter)

PROJECT #/S:

COUNTY/S:

FEDERAL:

PIN:

DESCRIPTION:

UTILITY CONTRACT #:

The Utility completed their utility relocation on(date of completion) in accordance with the approved relocation

plans for the above referenced project number prior to the date specified and in accordance with the executed contract referenced.

NOTE EXCEPTIONS:

Maintaining services to business and/or residences is attached.

Signed:

Date:

Print Name:

Title:

Utility Name:

WaterTelephone

Address:

SewerCATV

City, State, Zip:

PowerOther:

Phone No:

Gas

Fax No:

Email:

This Certification Letter is accepted.

This Certification Letter is accepted pending Final Verification by

project staking.

This Certification is not accepted. Reason:

Signed:

Date:

CC: TDOT Construction Project File

TDOT Regional Utility Office

Revision 10-25-2013

TDOT Utility Form 2013-16

Page 5.1

TDOT Construction office representative

Certification Contract Obligation

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

TDOT USE ONLY:

Once the relocation of their facilities is complete, the Utility must complete this sheet and return to TDOT Construction Supervisor for approval and confirmation that the reloca-tion of their facilities is complete.

Make sure to reference the TDOT Contract No. which you will find in the Upper Right Corner of the Utility Relocation Contract between TDOT and the utility relocating on the project.

Once the Certification is approved, TDOT Construction will return the certification to the Utility with copies to the TDOT Headquarters in Nashville and also to the Regional Utility Office. Only then will the Utility be able to submit their invoice for reimbursem*nt along with the approved certification to TDOT for payment.

Move Prior Certification ObligationCover Sheet

Sheet 1.1

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Certification ExceptionsCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

CERTIFICATION EXCEPTIONS:

Type of Utility Service

(water, sewer, gas,

electric, CATV)

Remarks:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Revision 10-25-2013 TDOT Utility Form 2013-16

Type of

Occupied

Property

Period of time utility

obligates to remove facility

(Calendar Days)

Address

The following business and/or residences on proposed State right-of-way have not been vacated at the time of the relocation, and utility

services are being maintained temporarily. Upon written notice to the utility contact listed below, the utility will

State Project

Tract No.

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The Declaration of Scheduled Calendar Days must be filled out and signed by the Utility for both “move prior” and “move in” relocation projects.

Note that all estimated days are to be expressed in “calendar” days, not “business or work” days. The “Total Days To Complete” will automatically be filled in as the other three tasks are assigned days for completion.

If there are any special conditions to the relocation of the facilities, number the conditions in the lines provided, and note the number in the appro-priate block of the table above.

Declaration of Scheduled Calendar DaysCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

Project Number: Date:

Description:

County:

Utility Name:

Address:

City, State: Zip Code:

Phone Number:

Type of Facilities: Water Sewer Gas Telephone Electric

CATV Fiberoptic Other

Required Period services cannot be interrupted:

Special Conditions:

Signature of submitting Date Signature of submitting Date

Utility Representative State Representative

Revisioin 10-25-2013 TDOT Utility Form 2013-16

Page 6.1

Declaration of Scheduled Calendar Days

January 27, 2014

All estimated days should be expresses in "Calendar" days to complete installation, relocation or

Fax Number:

adjustment of the utility facilities on the above referenced project. The utility can as an option submit an

"On or Before" date all work will be completed. In accordance with provisions set forth in TCA 54-5-854.

Subject to provisions of the TDOT Utility Office Maintenance of Traffic Procedures.

Stock Pile Material (Including ordering

material)

Mobilize Work Force (including Bidding

process if Required)

Complete Relocation

Total Days To Complete

Task Special ConditionsDays to Complete

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Maintenance of Traffic Procedures

When putting together an esti-mate for calendar days, take into consideration days in which TDOT will not allow traffic restrictions or lane closures. These days are as follows:

• Good Friday

• Easter - After 6:00 pm on the Thursday preceding Good Friday through and including Easter Sunday

• Memorial Day - After 12:00 noon on the preceding Friday through Memorial Day

• July 4 - The observed holiday and preceding day plus weekend days either preceding or following these two days

Cover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

Revision 10-25-2013 TDOT Utility Form 2013-16

Page 6.2

Except in emergencies, no lane closures will be permitted on any state routes with 30,000 or greater Average Daily

traffic or any interstate routes, without the explicit consent of the TDOT Project Engineer. On projects where work

is required in traffic lane(s) or where a lane closure is necessary for public safety, the Utility must submit a request

to the Department at least seven (7) working days prior to the date of the anticipated lane closure(s). All requests

for lane closure(s) must list the exact location, the time that the closure will begin, the estimated duration and

reasons for the proposed lane closure(s).

If all lanes in one or both directions on an interstate route are to be closed for any length of time, the Utility

must submit their request at least fourteen (14) calendar days before the anticipated event.

No lane closures or traffic restrictions will be allowed on the following days

Good Friday

Easter

After 6:00 pm on the Thursday preceding Good Friday through and including Easter Sunday

Memorial Day

After 12:00 noon on the preceding Friday through Memorial Day

July 4

The observed holiday and preceding day plus weekend days either preceding or following these two days

Labor Day

After 12:00 noon on the preceding Friday through Labor Day

Thanksgiving

After 12:00 noon on Wednesday before Thanksgiving through Sunday following Thanksgiving

Christmas/New year’s Day

December 24 through January 1 and any preceding and/or following days that fall on a weekend

Offroad work will be allowed but only to the extent that NO impact will be caused to the highway users.

During any suspension of work, the Utility shall make passable and shall open to traffic such portions of the

project and temporary roadways or portions thereof as may be directed by the TDOT Project Engineer for the

temporary accommodation of necessary traffic during the anticipated period of suspension. Thereafter, and

until issuance of an order for the resumption of construction operations, the maintenance of the temporary

route or line of travel will be by the Utility. When work is resumed, the Utility will replace or renew any work

or materials lost or damaged because of such temporary use of the project; shall remove, to the extent

directed by the TDOT Project Engineer, any work or materials used in the temporary maintenance, and shall

complete the project in every respect as though its prosecution had been continuous.

TDOT Utility Office Maintenance of Traffic Procedures.

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TDOT Utility Form 2013-16

Page 6.2

Except in emergencies, no lane closures will be permitted on any state routes with 30,000 or greater Average Daily

traffic or any interstate routes, without the explicit consent of the TDOT Project Engineer. On projects where work

is required in traffic lane(s) or where a lane closure is necessary for public safety, the Utility must submit a request

to the Department at least seven (7) working days prior to the date of the anticipated lane closure(s). All requests

for lane closure(s) must list the exact location, the time that the closure will begin, the estimated duration and

reasons for the proposed lane closure(s).

If all lanes in one or both directions on an interstate route are to be closed for any length of time, the Utility

must submit their request at least fourteen (14) calendar days before the anticipated event.

No lane closures or traffic restrictions will be allowed on the following days

Good Friday

Easter

After 6:00 pm on the Thursday preceding Good Friday through and including Easter Sunday

Memorial Day

After 12:00 noon on the preceding Friday through Memorial Day

July 4

The observed holiday and preceding day plus weekend days either preceding or following these two days

Labor Day

After 12:00 noon on the preceding Friday through Labor Day

Thanksgiving

After 12:00 noon on Wednesday before Thanksgiving through Sunday following Thanksgiving

Christmas/New year’s Day

December 24 through January 1 and any preceding and/or following days that fall on a weekend

Offroad work will be allowed but only to the extent that NO impact will be caused to the highway users.

During any suspension of work, the Utility shall make passable and shall open to traffic such portions of the

project and temporary roadways or portions thereof as may be directed by the TDOT Project Engineer for the

temporary accommodation of necessary traffic during the anticipated period of suspension. Thereafter, and

until issuance of an order for the resumption of construction operations, the maintenance of the temporary

route or line of travel will be by the Utility. When work is resumed, the Utility will replace or renew any work

or materials lost or damaged because of such temporary use of the project; shall remove, to the extent

directed by the TDOT Project Engineer, any work or materials used in the temporary maintenance, and shall

complete the project in every respect as though its prosecution had been continuous.

TDOT Utility Office Maintenance of Traffic Procedures.

Maintenance of Traffic ProceduresCover Sheet

Sheet 1.1

Sheet 2.1

Sheet 3.1

Sheet 4.1

Sheet 4.2

Sheet 5.1

Sheet 5.2

Sheet 6.1

Sheet 6.2

• Labor Day - After 12:00 noon on the preceding Friday through Labor Day

• Thanksgiving - After 12:00 noon on Wednesday before Thanksgiving through Sunday following Thanksgiving

• Christmas/New year’s Day - December 24 through January 1 and any preceding and/or following days that fall on a weekend

Off-road work will be allowed but only to the extent that NO impact will be caused to the highway users.

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

Once the requirements have been met to satisfy the “A” date for a project, the next submission for relocation will be at the “B” date submittal.

The “B” date submittal consists of completed utility relocation design, construction specifications and an updated construction estimate using the Master Consultant Excel Spreadsheet (MCES) provided to the utility by TDOT . The MCES is to be filled out and included with the “B” date submittal.

Utility relocation design must be completed in Microstation (.dgn format) or other CAD program as approved by TDOT. When the final submittal is sent in for the relocation, the Utility (or Consultant working for the utility) will be required to submit, along with all of the other required information, electronic CAD files of the final relocation design.

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

The Master Consultant Excel Spreadsheet (MCES) spreadsheet cannot be modified by the Utility or the Consultant. It must be filled out “as-is” in order to be processed properly when submitted to TDOT. Once a utility or consultant has prepared an accurate listing of Unit Items required for the successful relocation of the facilities owned by the utility, that information will be listed on the Master Consultant Excel Spreadsheet (MCES) spreadsheet and submitted to TDOT. The Standard Utility Item Numbers that are to be used on can be found on TDOT’s website. Each Utility has it’s own standard set of Item Numbers that must be used when relocating facilities on TDOT Roadway projects.

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

Completed PDF format of drawings are to be 22”x34” in size and must follow the guidelines set forth by TDOT for approved layout and information. Each Utility will be assigned a “U-series” number by TDOT to use for their specific utility (ex. U2-X, U3-X, etc.). This number is to be used when numbering the sheets for the relocation design.

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

The Cover sheet (sheet UX-1) must contain the following information:

• Index of drawings in the upper left corner

• Estimated Quantities table for the project

• Utility Information (Utility Name, Address, Contact Name, Phone, Fax and Email) in the lower left corner

• A legend may also be included, and if so, must be placed in the lower right corner of the sheet

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

The Plan sheets are to be laid out as close to the TDOT Present Layout sheets as possible, including match lines. Plan View sheets do not need to include the fol-lowing information:

• Curve Data

• Property Owner Information

• Bearing and Distances

• Track Numbers

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“B” Date Requirements, Utility Items and Final Relocation Drawings (In State Contract)

Misc. Sheets should follow directly behind the Plan sheets, and may include the following information:

• General Notes

• Location Information (station & offsets, northing & easting, etc.)

• Misc. Details

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Cover Sheet Layout

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Plan Sheet Layout

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Item Number: The Utility Item Number that has been assigned by TDOT for the specific Unit as listed in the TDOT Standard Item Numbers.

Description: Description as it is listed in the TDOT Standard Utility Item Numbers.

Unit: The type of Unit for which the Item shall be priced and paid (ex. EA, LF, LS, CY, etc.)

Unit Price: Combined Labor and Material Price for the Unit described.

Quantity: Total quantity of Units required for the entire project

Extension: Total Cost of the Units listed for the relocation of the facilities for the project.

Master Consultant Excel Spreadsheet (MCES)

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Utility Requirements – Move In State Contract

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Utility Requirements – Move In State Contract

When a Utility decides to MOVE IN the state contract, there is certain information that the utility needs to provide to TDOT and the General Contractor to assist in the relocation of their facilities. The information needed is as follows:

TDOT

• Detailed Relocation Plans

• Detailed Construction Specifications

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Utility Requirements – Move In State Contract

Contractor – Specify to the contractor exactly what the Utility wants concerning…

• Time periods of acceptable service outages

• Requirements for License, Certification, Drug testing of workers doing the relocation

• Liability Insurance requirements

• Approval of material submitted to the utility

• Approval of shop drawings submitted to the utility

• Approval of field changes submitted to the utility

• Approval of substitution materials or methods submitted to the utility

• Clearing and trimming of overhead lines inside/outside public ROW

• Locating utility lines during construction that are not identified by utility locate services

• Industry standards, safety standards and materials standards that are required by the utility

• Name, address, phone number, email, fax and cell phone of approved utility contact personnel

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Utility Requirements – Utility Diaries and Inspections

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Utility Requirements – Utility Diaries and Inspections

When the Utility Relocation is included in the State Contract, the Utility is responsible for providing inspection services on all phases of the relocation, per TCA 54-5-804, 2003 Public Chapter 86. A portion of inspection services may be reimbursable under Chapter 86 if a portion of the relocation is on existing Private ROW.

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Utility Requirements – Utility Diaries and Inspections

The inspector for the Utility will be provided a Project Utility Diary (TDOT Form DT-0667), along with Form DT-1716 (Utility Item Certification/Final Acceptance) and Form DT-1716A (Summary of Installed Utility Items). The responsibilities of the inspector provided by the utility company are as follows:

• Complete TDOT Form DT-0667 and submit it each estimate period, as directed by the TDOT Project Supervisor. Along with the item descriptions, the inspector will include the quantities and stations of installed items.

• Complete “Installed Item Certification” portion of TDOT Form DT-1716 (UTILITY ITEM CERTIFICATION/FINAL ACCEPTANCE) and submit it each estimate period, as directed by the TDOT Project Supervisor. This form will be signed to certify that the items installed during that estimate period met all applicable specifications.

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Utility Requirements – Utility Diaries and Inspections

• Complete and attach TDOT Form DT-1716A (SUMMARY OF INSTALLED UTILITY ITEMS) to DT-1716 and submit it each estimate period, as directed by the TDOT Project Supervisor. This form will be used to summarize, by project number, the utility items installed during that estimate period.

• Complete “Final Acceptance of Work” portion of TDOT Form DT-1716 and submit it to the TDOT Project Supervisor’s office when the utility relocation work is complete.

When a Utility is relocating at its own expense or under a lump sum reimbursem*nt con-tract, the “Description of Work Performed” section of TDOT Form DT-0667 will be the only notation required. The notation shall indicate if the relocation is a non-reimbursable or lump sum reimbursem*nt contract.

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52

TDOT Form DT-0667 (Project Utility Diary)

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53

TDOT Form DT-1716

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54

TDOT Form DT-1716A

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55

TDOT “Go To Work” Letters

STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION NASHVILLE, TN 37243-0360

JOHN C. SCHROER BILL HASLAM COMMISSIONER GOVERNOR

Begin Work Authorization Date: 5/24/2011

JOE SHAW

TENNESSEE DEPARTMENT OF TRANSPORTATION Power

SUITE 600, JAMES K. POLK BUILDING

NASHVILLE, TN 37243

PROJECT#/S: XXXXX-XXXX-XX COUNTY/S: WILSON

FEDERAL: XX-XXX-XXX(XX) PIN #: 123456.00

DESCRIPTION: SAMPLE ROADWAY PROJECT TYPE: 54-5-804 MOVE-IN STATE CONTRACT

Please refer to the above captioned project number on all correspondence concerning utility relocation.

Dear Mr. Joe Shaw,

This is to notify you to proceed with adjustment of facilities as shown on the enclosed, approved utility relocation plan for the above mentioned project. On the basis of this notice, you should proceed on this project as follows:

A) If contract is to relocate facilities PRIOR to the State Roadway contract, then:

1. Proceed in ordering materials and/or begin work IMMEDIATELY in order to clear the roadway for the construction of this project at the earliest possible date.

2. Submit the Certification Contract Obligation form (TDOT Form 2004-16, Sheets 7.1 & 7.2) to the Project Engineer listed below for the completion of the utility relocation to maintain eligibility for reimbursem*nt prior to the date specified on the contract.

3. All State right-of-way may not be available as of this date. Utility needs to verify with this office if a specific tract is available before beginning construction if the schedule depends on access.

B) If contract is to relocate facilities IN the State Roadway contract, then please proceed in ordering any Owner Furnished materials that will be supplied for the relocation of your facilities for the above mentioned project.

This project is currently scheduled for letting: 06/12/2012

You will be advised after the Letting Date of a Time and Location for the pre-construction conference.

Whether relocation is to be done IN the State Contract or PRIOR TO, the following information applies:

1. Billing is to be made in accordance with the provisions of 23 CFR 645A of the Federal Aid Policy Guide. Any charges billed by the utility that cannot be certified by the Regional Project Engineer’s records cannot be reimbursed.

2. Utility will be responsible for its own erosion control, clearing and grubbing and staking. The Utility is responsible for acquiring the TDEC Notice of Coverage (NOC) necessary for the work performed by the Utility.

3. All employees of this Department assigned to this project will be acting solely for highway construction purposes and shall not be held responsible for the location of utility facilities.

4. Three (3) days prior to the day that construction work is to be performed, the Utility must notify the Regional Project Engineer of the date the work is expected to begin to arrange for inspection and staking before doing actual work on the highway Right-of-way.

5. In accordance with TCA 54-5-854(h)(3) the Utility will submit monthly progress reports to the Project Engineer. PROJECT ENGINEER: David Reddon TELEPHONE: (615) 350-4382 x ADDRESS: 6601 Centennial Blvd., 3

rd Floor, Nashville, TN 37243-0360

Sincerely,

When the final contracts are signed by both the Utility and TDOT, TDOT will prepare a “Go To Work” letter that will be sent to the Utility along with a copy of the Final Contract for the project. This letter, although it is worded fairly generally, means differ-ent things to the Utility depending on the type of Contract the Utility has with TDOT for the relocation of their facilities. The differences are as follows:

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56

TDOT “Go To Work” Letters

Chapter 86 or Private/Public “Move In” Contracts

• If the Utility is moving their facilities in the state contract, and the State Contractor is supplying ALL of the Labor and Materials for the relocation of their facilities, then the Utility does not need to do anything.

• If the Utility is moving their facilities in the state contract, and they are supplying the materials, but the Contractor is supplying the Labor, then the Utility has authorization with the letter to start ordering and stockpiling the materials needed for the relocation once they receive the “Go To Work” letter.

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57

TDOT “Go To Work” Letters

Chapter 86 or Private/Public “Move Prior” Contracts or NO-COST Relocation

• If the Utility is moving their facilities prior to construction of the state contract, or if a Utility is relocating their facilities at NO-COST to the State, then the Utility has authorization with this letter to start the relocation of their facilities so that they are out of the way prior to the Letting Date for the project.

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58

Invoicing

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Invoicing

When invoicing TDOT for reimbursem*nt of expense (whether for Engineering or for Relocation), the following information will assist you in correctly submitting your invoices.

Process:

• Submit all invoices to the Regional Utility Office for review

• Invoices are then submitted to the Construction office for review and approval

• Once approved by the Construction office and the Regional Utility Office, invoices are then coded and submitted to accounts for payment.

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Invoicing

In order to expedite payment, follow the following guidelines…

• Submit invoices in the same format as the estimate

• Invoices MUST cite which sequential bill is being submitted (Progressive #1, #2, #3, etc.), and should list the total accumulated cost to date of the last bill

• Remember that progressive payments are capped at 80%

• Remember that if the final bill exceeds the contract amount, justification must be submitted for the excess amount

• Be sure to submit the final bill within one (1) year of the completion of the project

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Region Map and Contact Information

Below is a map showing the (4) regions of TDOT and how they are divided across the state.

REGION IV REGION III REGION II REGION I

61

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Contact Information for the Regional Utility Offices

Tommy Cox

300 Benchmark Place

Jackson, TN 38301

Phone: 731.935.0105

[emailprotected]

Jim Nikahd

6601 Centennial Blvd.

Nashville, TN 37243

Phone: 615.350.4233

[emailprotected]

Steve Langford

4005 Cromwell Road

Chattanooga, TN 37421

Phone: 423.510.1243

[emailprotected]

John Barrett

7345 Region Lane

Knoxville, TN 37914

Phone: 865.594.2484

[emailprotected]

62

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STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION NASHVILLE, TN 37243-0360

JOHN C. SCHROER BILL HASLAM COMMISSIONER GOVERNOR

Engineering Authorization Date: 5/24/2011 Federal Funds: 3/15/2011

JOE SHAW

TENNESSEE DEPARTMENT OF TRANSPORTATION Power

SUITE 600, JAMES K. POLK BUILDING

NASHVILLE, TN 37243

Project Eligible For

PROJECT#/S: XXXXX-XXXX-XX COUNTY/S: WILSON Chapter 86

FEDERAL: XX-XXX-XXX(XX) PIN #: 123456.00 Reimbursem*nt:

DESCRIPTION: SAMPLE ROADWAY PROJECT YES X NO

Please refer to the above captioned project number on all correspondence concerning utility relocation.

Dear Mr. Joe Shaw,

This letter will serve as authority for the Utility to proceed with ALL engineering that is necessary to prepare plans, schedule of working days, and estimates of cost for the adjustment of your facilities which may be in conflict with this project. This is done in accordance with the provisions of TCA 54-5-854.

If a consultant is needed, see paragraph “A” on page 2. Consultant package must be submitted and approved by this office before consultant engineering will be eligible for reimbursem*nt.

Estimates of cost prepared in response to this authorization are confidential and shall not be released or made available to anyone other than the Utility, the approved consultant, and TDOT.

Reimbursem*nt will be in accordance with TCA 54-5-804 and as amended by Public Chapter No. 86 of the Public Acts of 2003. The cost of any work done prior to the authorization date of this letter will not be eligible for reimbursem*nt.

This notice is not to be construed as authority to actually relocate any of your facilities. Any relocation work done prior to written approval from the State Utility Coordinator will not be eligible for reimbursem*nt.

This project is currently scheduled for letting: 06/12/2012

To be eligible for reimbursem*nt, if the project is qualified for Chapter 86 reimbursem*nt as noted above, the Utility MUST submit to this office for Location Approval by the revised due date (A): 10/14/2011

1) (5) half-sized, color coded relocation plans.

2) Completed TDOT Form 2004-16, including signed Schedule of Working Days and Chapter 86 Eligibility.

3) Utility declaration for reimbursem*nt.

In addition, to be eligible for inclusion of the utility relocation work in the State Construction contract, the following must be submitted by due date (B): 04/01/2012

1) PDF files of detailed Utility relocation plans.

2) PDF file of detailed Utility Specifications.

3) Completed Utility Item Spreadsheet in Excel format, including estimated construction costs.

4) Completed Utility individual permit sketches, if required.

The following will be provided to assist you in responding to the Department request:

SAMPLE

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Utility Name:

Utility Address:

City, State: Zip Code:

Phone:

Contact Name:

Email:

Consultant Name:

Consultant Address:

Zip Code:

Phone:

Contact Name:

Email:

Project Description:

Federal Project No.:

State Project No.:

County(ies):

October 2013

TDOT PROJECT INFORMATION

CONSULTANT INFORMATION

UTILITY ENGINEERING AND RELOCATION

ESTIMATE

UTILITY INFORMATION

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TDOT Project Number(s):

Utility Name & Address: Consultant Name & Address:

Place an "X" in the appropriate box: Standard Contract Continuing Contract (attach copy of Contract for TDOT verification)

I. ENGINEERING SERVICES

Classification Rate/Hr Hours Total Hours Total Hours Total

Principal -$ -$ -$ -$

Project Manager -$ -$ -$ -$

Design Engineer -$ -$ -$ -$

Designer / Senior Designer -$ -$ -$ -$

Techician / Draftsperson -$ -$ -$ -$

Administrative -$ -$ -$ -$

Field Inspector -$ -$ -$ -$

Licensed Surveyor -$ -$ -$ -$

Rod Person -$ -$ -$ -$

-$ -$ -$ -$

0 -$ 0 -$ 0 -$

II. REIMBURSABLE EXPENSES

Cost/Unit Quantity Total Quantity Total Quantity Total

Transportation / Mile: 0.47$ X = -$ -$ = -$

Meals / Day: -$ X = -$ -$ = -$

Lodging / Day: -$ X = -$ -$ = -$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses -$ -$ -$

Indirect/Overhead Rate (not to exceed 145%): 0.00% -$ 0.00% -$ 0.00% -$

Allowable Rate (Maximum of 13%): 0.00% -$ 0.00% -$ 0.00% -$

TOTAL ENGINEERING / SURVEY COST:

Standard Consultant: (I+II+III+IV) = -$ Private: -$ Private: -$

Continuing Contract: (I+II) = -$ Public: -$ Public: -$

Standard Consultant: -$

Continuing Contract: -$

I. ENGINEERING SERVICES

Classification Rate/Hr Hours Total Hours Total Hours Total

Project Manager -$ -$ -$ -$

Engineer -$ -$ -$ -$

Draftperson -$ -$ -$ -$

Administrative -$ -$ -$ -$

Field Inspector -$ -$ -$ -$

Licensed Surveyor -$ -$ -$ -$

Rod Person -$ -$ -$ -$

-$ -$ -$ -$

0 -$ 0 -$ 0 -$

II. REIMBURSABLE EXPENSES

Cost/Unit Quantity Total Quantity Total Quantity Total

Transportation / Mile: 0.47$ X = -$ -$ = -$

Meals / Day: -$ X = -$ -$ = -$

Lodging / Day: -$ X = -$ -$ = -$

Printing / Shipping:

Other (Specify):

Other (Specify):

Total Reimbursable Expenses -$ -$ -$

Indirect/Overhead Rate (not to exceed 145%): 0.00% -$ 0.00% -$ 0.00% -$

-$ Private: -$

Public: -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 1.1

0 0

TOTAL ENGINEERING COST: TOTAL INSPECTION COST:

ESTIMATE OF ENGINEERING COST

CONSULTANT ENGINEERING ESTIMATE

IN-HOUSE ENGINEERING ESTIMATE

III. INDIRECT / OVERHEAD EXPENSES

PRE-CONSTRUCTION/CONSTRUCTION FIELD SURVEYING CONSTRUCTION INSPECTION

Total Engineering Services

County(ies):

TOTAL COST (Engineering and Inspection)

(Expenses for Sections III and IV only apply to Consultant Engineering Services without a Continuing Contract agreement with the Utility)

INSPECTION (Standard) INSPECTION (Continuing)

Total Engineering Services

CONSTRUCTION INSPECTIONFIELD SURVEYINGPRE-CONSTRUCTION/CONSRUCTION

IV. PROFIT: (2.35x(1,2,3)x ALLOWABLE RATE)

III. INDIRECT / OVERHEAD EXPENSES

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EQUIPMENT COST INCLUDED WITH INSTALLATION COST

TDOT Item No. Item Description Qty Unit Cost Extended Unit Cost Extended

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

-$ -$ -$

TOTAL INSTALLATION COSTS -$ -$ -$ -$ -$ -$

TDOT Item No. Item Description Qty Unit Cost Extended Unit Cost Extended Clearing & Grubbing: -$

-$ -$ Traffic Control: -$

-$ -$ Erosion Control: -$

-$ -$

-$ -$ TOTAL SITE COST -$

-$ -$ -$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

-$ -$

TOTAL REMOVAL COSTS -$ -$ -$ -$ -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 2.1

Salvage Value:

If scrapped material is saleable, the

estimated sale value must be shown as

a credit. If no net value, must footnote

that the item has no value.

Percentage:

Salvage Value to be established by

using "Salvage Value Percentage"

calculation.

INSTALLATION LABOR AND MATERIALS; BETTERMENT; MATERIALS PROVIDED TO THE STATE

REMOVAL LABOR; SALVAGE AND NON-USABLE (JUNKED) MATERIALS

(Move Prior Only)

Labor Material

BETTERMENT

SITE COSTS

LABOR

In House Cost Contract (Bid/Continuing)

MATERIAL

Unit Cost

In House Cost

LABOR

Provided to StateInstall

Extended

MATERIAL

Salvage / Reused

Contract (Bid/Continuing) Junked /

Scrapped

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EXISTING

EAsem*nT (SF)

PROPOSED

EAsem*nT (SF)

SURVEY &

ENGINEERING COSTATTORNEYS FEES

RECORDING &

OFFICE COSTEAsem*nT COST

SHEET SUBTOTAL

COST

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

-$ -$ -$ -$ -$

Total Easem*nt Acquisition Expenses TOTAL -$

STANDARD CONTINUING STANDARD CONTINUING

$ - $ - -$ -$ -$

-$ -$

Revision 10-25-2013 TDOT Utility Form 2013-16

Sheet 3.1

NO - the utility will not seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

YES - the utility will seek reimbursem*nt of eligible inspection expenses (PRIVATE) incurred in accordance with TCA 54-5-804 (a)(3)

-$

Replacement Easem*nt Acquisition Expenses

INSPECTION COSTS (PUBLIC)

CONSULTANTIN-HOUSE IN-HOUSE

Attached Additional Sheets: Y / N

SHEET NUMBER

CONSULTANT

INSPECTION COSTS (PRIVATE)

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Project No:

County:

Date:

Primary Contact:

E-mail: Phone:

Secondary Contact: RG Approval and Date:

E-mail: Phone:

Utility Name: Consult Appr. Date: / /

Address: Amount Approved: -$

City, State: Zip: 0 HQ Approval and Date:

Percent On Private: 0% Private ROW - #Poles / Length of facility: CH86 Y / N PIN#:

Percent On Public: 0% Public ROW - #Poles / Length of facility: LET: / / Contract #:

Total Percentage: 0% Total #Poles / Length of facility: 0 Easem*nt Contract #

N

REIMBURsem*nT MOVE PRIOR % Private / Public Relocation

REQUESTED MOVE IN State Contract % Private / Public MOVE IN State Contract

(Please check ONE) Other Utility Replacement Easem*nt Reimbursem*nt

Amount

Pre-Construction / Construction -$ -$

-$

-$ -$

-$

-$

-$

-$

Amount N

-$ Y

-$

-$

-$

-$

-$ RELOCATION EXCEEDS $1.75M CAP: -$

-$

AMOUNT OVER 75% REIMBURsem*nT: -$

-$

Amount

-$ CHAPTER 86 MOVE-IN CONTRACT: -$

-$

NON-CHAPTER 86 MOVE-IN CONTRACT: -$

-$

-$

ESTIMATED TOTAL CONSTRUCTION COST: $ -

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Page 4.1

UTLITY DEPOSIT (IF APPLICABLE)

ENGINEERING COST:

Description

BETTERMENT

ESTIMATED CONSTRUCTION COST:

Does Estimate Exceed $1.75M Cap? -

Does Estimate Require 75% Cap? -

CHAPTER 86 MOVE PRIOR:

NON-CHAPTER 86 MOVE-IN CONTRACT:

NON-CHAPTER 86 MOVE PRIOR:

CONSTRUCTION (LABOR & MATERIAL)

January 27, 2014

Description

NO COST / NO REIMBURsem*nT (STOP HERE, REMAINDER OF FORM IS NOT REQUIRED)

TDOT USE ONLY

Is Utility Chapter 86 Certified (Obtained from Certification Sheet)?

(If project does not qualify for Chapter 86 Reimbursem*nt, then "Percent on Private" will be used to calculate total amount due to Utility)

NON-CHAPTER 86CHAPTER 86

ENGINEERING

Installation Materials

Removal Labor

Site Costs

Material Provided to State

Salvage Materials

Non-Usable Materials

**Submittal and completion of this form is required for consideration of reimbursem*nt on this project.**

Field Surveying

Construction Inspection

Reimbursable Expenses

Installation Labor

UTILITY REIMBURsem*nT

CHAPTER 86 MOVE-IN CONTRACT:

If cost is listed above, separate Easem*nt Contract is needed

AMOUNT TO BE PAID BY THE UTILITY

Installation Labor

Installation Materials

Description

The Utility will reference the page number where designated on the form when other Detail Cost Estimate sheets are attached.

ESTIMATED UTILITY BETTERMENT COST:

ESTIMATED REPLACEMENT EAsem*nT COST:

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PROJECT #/S: COUNTY/S:

FEDERAL: PIN:

1. The utility is seeking reimbursem*nt under provisions of TCA 54-5-804 as ameneded by Public Acts 2003, Chapter number 86.

Water

Waste Water

Gas Distribution Transmission

Electric Distribution Transmission

Communication CATV Phone Fiberoptic Broadband

Street Lighting

Other

Signature: Date:

Print Name:

Title:

Utility Name:

Utility Address:

City, State, Zip:

Phone Number:

Fax Number:

Email Address:

Revision 10-25-2013 TDOT Utility Form 2013-16

Page 4.2

Municipally Owned Utility District Utility Cooperative

Chapter 86 Certification

5. The utility is considered to be a specific utility category listed in accordance with the Limitation provisions of the TDOT Policy 340-07:

4. The utility is eligible for reimbursem*nt in accordance with the Limitation provisions of the TDOT Policy 340-07 in that it is:

3. To the best of my knowledge the utility is in compliance with TCA 54-5-804(b) in that the utility has a valid permit to locate its utility

facility on the public highway right-of-way.

In accordance with Tennessee Department of Transportation policy number 340-07, the following information is provided

with regards to required compliance documentation for utility relocation reimbursem*nt in accordance with TCA 54-5-804

and TCA 54-5-854.

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

2. To the best of my knowledge the utility is in compliance with TCA § 54-5-804(a)(1) and this policy in that the utility has returned its

relocation plan, schedule, and cost estimate to the Department within 120 days after receipt of the Department’s project plans, or

within such additional time as may be allowed in accordance with TCA § 54-5-854(b).

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Date: TDOT Region Construction Office

(Region)

Attn: ,Project Engineer

Address:

(information is provided on the Utility Begin Work Authorization letter)

PROJECT #/S: COUNTY/S:

FEDERAL: PIN:

DESCRIPTION:

UTILITY CONTRACT #:

The Utility completed their utility relocation on (date of completion) in accordance with the approved relocation

plans for the above referenced project number prior to the date specified and in accordance with the executed contract referenced.

NOTE EXCEPTIONS:

Maintaining services to business and/or residences is attached.

Signed: Date:

Print Name:

Title:

Utility Name: Water Telephone

Address: Sewer CATV

City, State, Zip: Power Other:

Phone No: Gas

Fax No:

Email:

This Certification Letter is accepted.

This Certification Letter is accepted pending Final Verification by

project staking.

This Certification is not accepted. Reason:

Signed: Date:

CC: TDOT Construction Project File

TDOT Regional Utility Office

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Page 5.1

TDOT Construction office representative

Certification Contract Obligation

Signature indicates this individual has the legal authority to sign contracts and agreements to obligate the utility.

TDOT USE ONLY:

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CERTIFICATION EXCEPTIONS:

Type of Utility Service

(water, sewer, gas,

electric, CATV)

Remarks:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

Revision 10-25-2013 TDOT Utility Form 2013-16

Type of

Occupied

Property

Period of time utility

obligates to remove facility

(Calendar Days)

Address

The following business and/or residences on proposed State right-of-way have not been vacated at the time of the relocation, and utility

services are being maintained temporarily. Upon written notice to the utility contact listed below, the utility will

State Project

Tract No.

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Project Number: Date:

Description:

County:

Utility Name:

Address:

City, State: Zip Code:

Phone Number:

Type of Facilities: Water Sewer Gas Telephone Electric

CATV Fiberoptic Other

Required Period services cannot be interrupted:

Special Conditions:

Signature of submitting Date Signature of submitting Date

Utility Representative State Representative

Revisioin 10-25-2013 TDOT Utility Form 2013-16

Page 6.1

Declaration of Scheduled Calendar Days

January 27, 2014

All estimated days should be expresses in "Calendar" days to complete installation, relocation or

Fax Number:

adjustment of the utility facilities on the above referenced project. The utility can as an option submit an

"On or Before" date all work will be completed. In accordance with provisions set forth in TCA 54-5-854.

Subject to provisions of the TDOT Utility Office Maintenance of Traffic Procedures.

Stock Pile Material (Including ordering

material)

Mobilize Work Force (including Bidding

process if Required)

Complete Relocation

Total Days To Complete

Task Special ConditionsDays to Complete

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Page 6.2

Except in emergencies, no lane closures will be permitted on any state routes with 30,000 or greater Average Daily

traffic or any interstate routes, without the explicit consent of the TDOT Project Engineer. On projects where work

is required in traffic lane(s) or where a lane closure is necessary for public safety, the Utility must submit a request

to the Department at least seven (7) working days prior to the date of the anticipated lane closure(s). All requests

for lane closure(s) must list the exact location, the time that the closure will begin, the estimated duration and

reasons for the proposed lane closure(s).

If all lanes in one or both directions on an interstate route are to be closed for any length of time, the Utility

must submit their request at least fourteen (14) calendar days before the anticipated event.

No lane closures or traffic restrictions will be allowed on the following days

Good Friday

Easter

After 6:00 pm on the Thursday preceding Good Friday through and including Easter Sunday

Memorial Day

After 12:00 noon on the preceding Friday through Memorial Day

July 4

The observed holiday and preceding day plus weekend days either preceding or following these two days

Labor Day

After 12:00 noon on the preceding Friday through Labor Day

Thanksgiving

After 12:00 noon on Wednesday before Thanksgiving through Sunday following Thanksgiving

Christmas/New year’s Day

December 24 through January 1 and any preceding and/or following days that fall on a weekend

Offroad work will be allowed but only to the extent that NO impact will be caused to the highway users.

During any suspension of work, the Utility shall make passable and shall open to traffic such portions of the

project and temporary roadways or portions thereof as may be directed by the TDOT Project Engineer for the

temporary accommodation of necessary traffic during the anticipated period of suspension. Thereafter, and

until issuance of an order for the resumption of construction operations, the maintenance of the temporary

route or line of travel will be by the Utility. When work is resumed, the Utility will replace or renew any work

or materials lost or damaged because of such temporary use of the project; shall remove, to the extent

directed by the TDOT Project Engineer, any work or materials used in the temporary maintenance, and shall

complete the project in every respect as though its prosecution had been continuous.

TDOT Utility Office Maintenance of Traffic Procedures.

GSP TDOT Utility Presentation - [PDF Document] (75)

GSP TDOT Utility Presentation - [PDF Document] (76)

GSP TDOT Utility Presentation - [PDF Document] (77)

GSP TDOT Utility Presentation - [PDF Document] (78)

STATE OF TENNESSEE

DEPARTMENT OF TRANSPORTATION NASHVILLE, TN 37243-0360

JOHN C. SCHROER BILL HASLAM COMMISSIONER GOVERNOR

Begin Work Authorization Date: 5/24/2011

JOE SHAW

TENNESSEE DEPARTMENT OF TRANSPORTATION Power

SUITE 600, JAMES K. POLK BUILDING

NASHVILLE, TN 37243

PROJECT#/S: XXXXX-XXXX-XX COUNTY/S: WILSON

FEDERAL: XX-XXX-XXX(XX) PIN #: 123456.00

DESCRIPTION: SAMPLE ROADWAY PROJECT TYPE: 54-5-804 MOVE-IN STATE CONTRACT

Please refer to the above captioned project number on all correspondence concerning utility relocation.

Dear Mr. Joe Shaw,

This is to notify you to proceed with adjustment of facilities as shown on the enclosed, approved utility relocation plan for the above mentioned project. On the basis of this notice, you should proceed on this project as follows:

A) If contract is to relocate facilities PRIOR to the State Roadway contract, then:

1. Proceed in ordering materials and/or begin work IMMEDIATELY in order to clear the roadway for the construction of this project at the earliest possible date.

2. Submit the Certification Contract Obligation form (TDOT Form 2004-16, Sheets 7.1 & 7.2) to the Project Engineer listed below for the completion of the utility relocation to maintain eligibility for reimbursem*nt prior to the date specified on the contract.

3. All State right-of-way may not be available as of this date. Utility needs to verify with this office if a specific tract is available before beginning construction if the schedule depends on access.

B) If contract is to relocate facilities IN the State Roadway contract, then please proceed in ordering any Owner Furnished materials that will be supplied for the relocation of your facilities for the above mentioned project.

This project is currently scheduled for letting: 06/12/2012

You will be advised after the Letting Date of a Time and Location for the pre-construction conference.

Whether relocation is to be done IN the State Contract or PRIOR TO, the following information applies:

1. Billing is to be made in accordance with the provisions of 23 CFR 645A of the Federal Aid Policy Guide. Any charges billed by the utility that cannot be certified by the Regional Project Engineer’s records cannot be reimbursed.

2. Utility will be responsible for its own erosion control, clearing and grubbing and staking. The Utility is responsible for acquiring the TDEC Notice of Coverage (NOC) necessary for the work performed by the Utility.

3. All employees of this Department assigned to this project will be acting solely for highway construction purposes and shall not be held responsible for the location of utility facilities.

4. Three (3) days prior to the day that construction work is to be performed, the Utility must notify the Regional Project Engineer of the date the work is expected to begin to arrange for inspection and staking before doing actual work on the highway Right-of-way.

5. In accordance with TCA 54-5-854(h)(3) the Utility will submit monthly progress reports to the Project Engineer. PROJECT ENGINEER: David Reddon TELEPHONE: (615) 350-4382 x ADDRESS: 6601 Centennial Blvd., 3

rd Floor, Nashville, TN 37243-0360

Sincerely,

GSP TDOT Utility Presentation - [PDF Document] (2024)
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