Project No. ______

CONSTRUCTION PROJECT REQUEST FORM

This form is to be used to request Measure A, Measure E, and other funding support for construction and scheduled maintenance projects and related furniture and equipment expenditures.

INCOMPLETE SUBMITTALS WILL BE RETURNED

INSTRUCTIONS:

1.  Complete SECTIONS I AND II

2.  Obtain required signatures and approvals prior to submittal

3.  Forward the completed Instructional expenditure request form to:

CONSTRUCTION PROJECT REQUEST FORM

SECTION I - PROJECT BACKGROUND
(Check one) / MEASURE A / MEASURE E / OTHER
Date:
Requestor:
Phone No.
Location: / District / Laney / COA / Merritt / Berkeley City College
Department : / Building:
Requested Funding Amount:
Project Name:

1. Which best describes this project?

Peralta Community College District Department of General Service

Form Revised: March 10, 2014 Page 6 of 6

Project No. ______

Health and Safety

Emergency Maintenance

Upgrade to an Existing Facility

Classroom

Laboratory

Administrative Space

Student Area

Public Area

Roads and Walkways

Grounds

Create New Facility Space

Other:

Peralta Community College District Department of General Service

Form Revised: March 10, 2014 Page 6 of 6

Project No. ______

2.  Project will require the following:

ARCHITECTURAL / MECHANICAL / ELECTRICAL / PLUMBING
Walls/Partitions Plastering
Masonry/Concrete Windows
Doors/Hardware
Waterproofing
Insulating
Roofing/Gutters Woodwork
Other: / Window A/C
Central A/C
Temp/Humid Controls
Ductwork
Diffusers/Grilles
Exhaust Fan
Fume Hood
Other: / Lighting Fixtures
Receptacles/GFCI
Telecomm Outlets
Power Other than 120V
Dedicated Circuits
Fire Alarm
Emergency Lighting
Other: / Domestic Water
Distilled Water
Air, Gas, Vacuum
Sink / Fixtures
Toilet / Fixtures
Drain Vent
Fire Sprinkler
Other:
FINISHING / FURNISHING / SPECIALTIES / OTHER SERVICES
Plastering
Drywall
Wall Coverings
Painting
Vinyl Tile/Base
Carpet/Base
Suspended Ceiling
Other: / Window Treatments
Fixed/Movable Seating
Modular Office Furniture
Labor arty Furniture
Display Case
Bookcase Shelving
Custom Woodwork
Other: / White/Tack Boards
Chalkboards
Toilet /Shower Partitions
Storage Shelving
Access Flooring
Directories/ Signs
Storage Shelving
Other: / Move
Special Event
Landscaping
Fencing
Rekey Door Hardware
Asbestos Removal
Demolition
Other:

3. Will this be a one-time expenditure? Yes No

If No, how will this project be incorporated as an on-going expenditure into the department, program, curriculum and budget?

4. Project description: (You may attach additional information)

5. Project justification: (Note: Project request must refer to Bond language, if applicable.)

6. What are the project objectives and benefits to the students, program, and college?

7. Project estimates: (Please names and list the final cost estimates from three different vendors, suppliers, or trades. In addition, please attach the original estimates.)

Name / Cost
1.
2.
3.

8. Appendix Description: (Please list any additional attachments, such as timelines, plans, sketches etc.)

SECTION II - PROJECT CONTACT INFORMATION
COLLEGE CONTACT INFORMATION
Contact:
Email: / Phone:
COLLEGE APPROVALS

1. OFFICE OF INSTRUCTIONAL SERVICES

Vice President of Instructional Services:
Signature: / (Print Name) / Date:
Email: / Phone:

2.  BUSINESS OFFICE

ACCOUNT CODES:

L / FUND / COST CENTER / OBJECT / PR / ACTIVITY / SPJ / LN
College Business Officer (Required for District Review):
Signature: / Date: / (Print Name)
Email: / Phone:

3. COLLEGE PRESIDENT’S OFFICE

College President (Required for District Review):
Signature: / Date: / (Print Name)
Email: / Phone:

SECTION III –EVALUATION

(DISTRICT USE ONLY)

To be Completed by the Department of General Services

1. Project Name:
2. Budget Expenditure:
3. Facilities Master Plan Scheduled Area Renovation date:
4. The next scheduled maintenance project date for this area:
5. The next scheduled renovation project date for this area:

6.  Recommendation:

Approved

Request Incomplete (Please complete highlighted areas) Return by:

Rejected (Review justification below)

APPROVED BY

Dr. Sadiq Ikharo; Vice Chancellor of General Services Date

Susan Rinne, Interim Vice Chancellor of Finance & Administration Date

Dr. José M. Ortiz, Chancellor Date

Peralta Community College District Department of General Service

Form Revised: March 10, 2014 Page 6 of 6