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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 on the utility capacities supplying the building? If yes, to what extent? FORMCHECKBOX FORMCHECKBOX X6.Will the project impact the heating plant or the primary electrical system supplying the campus or institution? If yes, to what extent? FORMCHECKBOX FORMCHECKBOX X7.Have you identified the WEPA designation of the project, Type I, Type II, TypeIII? FORMCHECKBOX Type III.8.Is the project affected by Historic Status? FORMCHECKBOX FORMCHECKBOX X9.Are there any other issues affecting the cost or status of this project? 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 X
All Agency Project Request
20##-## Biennium
DATE \@ "M/d/yyyy" 4/20/2009 FILENAME Document4page PAGE 1 of NUMPAGES 1
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