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AgencyInstitutionBuilding No.Building NameUniversity of WisconsinX285-0X-####XX
Project No.XProject TitleX
Project Intent
X
Project Description
X
Project Justification
X
Consultant RequirementsConsultants should have specific expertise and experience in the design and coordination of (GENERAL DESCRIPTION OF DISCIPLINES AND SPECIALITIES RELATED TO THIS SPECIFIC PROJECT REQUEST) as part of a design team. Work includes site surveys, acquiring field data, and verifying as-built conditions to assure accurate development of design and bidding documents, and production of necessary design and bidding documents. Consultants should indicate specific projects from past experience (including size, cost, and completion date) in their letter of interest and when known, include proposed consulting partners and specialty consultants. FORMCHECKBOX A consultant has been previously selected and approved for this project.
Project BudgetFunding SourceTotalConstruction Cost:$0GFSB [insert appropriate fund category]$0Haz Mats:$0PRSB [insert appropriate fund category]$0Total Construction:$0PR Cash$0Contingency:15 %$0Gifts$0A/E Design Fees:8 %$0Grants$0DFD Mgmt Fees:4 %$0BTF Planning$0Equipment/Other:$0Other - $0$0$0
Student Segregated Fee ImpactFiscal YearAnnual FeeDescribe/list segregated fee increases required to support this project request. Please include description of phased implementation, per year increases, detail any year by year differences, and describe the fee term duration.20## - ##$000.0020## - ##$000.0020## - ##$000.0020## - ##$000.0020## - ##$000.00
Project Schedule(MM/YYYY)Project ContactSBC Approval:Contact Name:XA/E Selection:Email:XBid Opening:Telephone:XConstruction Start:MM/YYYYSubstantial Completion:MM/YYYYProject Close Out:
Project Scope Consideration ChecklistYN1.Will the building or area impacted by the project be occupied during construction? If yes, explain how the occupants will be accommodated during construction. FORMCHECKBOX FORMCHECKBOX All project work will be coordinated through campus physical plant staff to minimize disruptions to daily operations and activities.2.Is the project an extension of another authorized project? If so, provide the project #... FORMCHECKBOX FORMCHECKBOX X3.Are hazardous materials involved? If yes, what materials are involved and how will they be handled? FORMCHECKBOX FORMCHECKBOX Required hazardous materials abatement (ENTER TYPES AND QUANTITIES OF MATERIALS HERE) has been included in the estimated project schedule and project budget. Comprehensive environmental survey inventory data (IS/IS NOT) available on Wisconsin's Asbestos & Lead Management System (WALMS) . - OR - Hazardous materials abatement is not anticipated on this project. Comprehensive environmental survey inventory data (IS/IS NOT) available on Wisconsin's Asbestos & Lead Management System (WALMS) .4.Will the project impact the utility systems in the building and cause disruptions? If yes, to what extent? FORMCHECKBOX FORMCHECKBOX X5.Will the project impact the heating plant, primary electrical system, or utility capacities supplying the building? If yes, to what extent? FORMCHECKBOX FORMCHECKBOX X6.Are other projects or work occurring within this projects work area? If yes, provide the project # and/or descripition of the other work in the project scope. FORMCHECKBOX FORMCHECKBOX X7.Have you identified the WEPA designation of the project, Type I, Type II, TypeIII? FORMCHECKBOX Type III.8.Is the facility listed on a historic register (federal or state), or is the facility listed by the Wisconsin Historical Society as a building of potential historic significance? If yes, describe here. FORMCHECKBOX FORMCHECKBOX X9.Are other studies, testing or investigations required to confirm the scope or existing conditions? If yes, describe here. FORMCHECKBOX FORMCHECKBOX X10.Will the construction work be limited to a particular season or window of opportunity? If yes, explain the limitations and provide proposed resolution. FORMCHECKBOX FORMCHECKBOX X11.Will the project improve, decrease, or increase the function and costs of facilities operational and maintenance budget and the work load? If yes, to what extent? FORMCHECKBOX FORMCHECKBOX X12.Are there known code or health and safety concerns? If yes, identify and indicate if the correction or compliance measure was included in the budget estimate, or indicate plans for correcting the work. FORMCHECKBOX FORMCHECKBOX X13.Are there potential energy or water usage reduction grants, rebates or incentives for which the project may quality (i.e. Focus on Energy or the local utility provider)? If yes, describe here. FORMCHECKBOX FORMCHECKBOX X14.If this an energy project, indicate and describe the simple payback on state funding sources in years and the expected energy reduction here. FORMCHECKBOX FORMCHECKBOX X
All Agency Project Request
2011-13 Biennium
DATE \@ "M/d/yyyy" 2/22/2010 FILENAME UWSA_1113_AAPR.docpage PAGE 1 of NUMPAGES 1
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