REQUEST FOR INSPECTION OF NURSERY TREES
/ MUST BE COMPLETED / CDOT Project Number: / Date:
Project Description:
IDOT Contract Number:
Resident Engineer & Cell:
Resident Engineer Email:
Resident Engineer to assign T-Number and retain records in job file. RE must send one completed copy to CDOT Quality Assurance (QA) 30 N. LaSalle, Suite 400 Chicago, IL 60602 for processing. / Project Completion Date:
Contractor:
Address:
Tel / Fax:
SENIORCITY FORESTER CONTACT INFORMATION / Subcontractor
(or Purchaser of Trees):
JEFF BRINK / CELL: / (312) 221-1654
EMAIL: / / Address:
LUBKA BENAK / OFFICE: / (312) 742-2837
EMAIL: / / Telephone / Fax:
FAX: / (312) 744-4758 OR (312) 744-3958 / EMAIL:
MUST BE COMPLETED / PAY
ITEM NO. / GENUS SPECIES CULTIVAR
(ITEM DESCRIPTION) / CALIPER
(INCHES) / SEASON OF PLANTING / QUANTITY / UNIT
NURSERY CERTIFICATION (Only one Nursery per Inspection Report). Nurseries must hold a current nursery certificate issued by the residing state.
NURSERY OF HARVEST: / I hereby certify that the items listed above to be used in construction of the subject project comply with all contract requirements.
NURSERY CODE:
ADDRESS: / Certified by Nursery Representative:
TELEPHONE: / Name:
EMAIL: / Title:
Tree Planting Permits are required from Department of Streets & Sanitation, Bureau of Forestry prior to tree planting.
FORESTRY CONTACT INFORMATION / JOHN KIRCHNER / EMAIL:
OFFICE: (312) 746-5254 / FAX: (312) 746-5254
COMPLETED BY ENGINEER / CITY / CITY ENDORSEMENT
The above material was inspected on (Date): / Inspection Report No.: / T-
Page of
Accepted By:
(SeniorCity Forester)
Approved by:
(Resident Engineer)
This RFINT has been reviewed by CDOT QA and has been found to be Acceptable.
Reviewer: / Date:
cc:Contractor
Resident Engineer
CDOT QA
CDOT Division Of Engineering–Eleanore Skopek / Revised 04/12
REQUEST FOR INSPECTION OF NURSERY TREES
/ MUST BE COMPLETED / CDOT Project Number: / 1 / Date: / 2
Project Description: / 3
IDOT Contract Number: / 4
Resident Engineer & Cell: / 5
Resident Engineer Email: / 6
Resident Engineer to assign T-Number and retain records in job file. RE must send one completed copy to CDOT Quality Assurance (QA) 30 N. LaSalle, Suite 400 Chicago, IL 60602 for processing. / Project Completion Date: / 7
Contractor: / 8
Address: / 9
Tel / Fax: / 10
SENIORCITY FORESTER CONTACT INFORMATION / Subcontractor
(or Purchaser of Trees): / 11
JEFF BRINK / CELL: / (312) 221-1654
EMAIL: / / Address: / 12
LUBKA BENAK / OFFICE: / (312) 742-2837
EMAIL: / / Telephone / Fax: / 13
FAX: / (312) 744-4758 OR (312) 744-3958 / EMAIL: / 14
MUST BE COMPLETED / PAY
ITEM NO. / GENUS SPECIES CULTIVAR
(ITEM DESCRIPTION) / CALIPER
(INCHES) / SEASON OF PLANTING / QUANTITY / UNIT
15 / 16 / 17 / 18 / 19 / 20
NURSERY CERTIFICATION (Only one Nursery per Inspection Report). Nurseries must hold a current nursery certificate issued by the residing state.
NURSERY OF HARVEST: / 21 / I hereby certify that the items listed above to be used in construction of the subject project comply with all contract requirements.
NURSERY CODE: / 22
ADDRESS: / 23 / Certified by Nursery Representative: / 26
TELEPHONE: / 24 / Name: / 27
EMAIL: / 25 / Title: / 28
Tree Planting Permits are required from Department of Streets & Sanitation, Bureau of Forestry prior to tree planting.
FORESTRY CONTACT INFORMATION: / JOHN KIRCHNER / EMAIL:
OFFICE: (312) 746-5254 / FAX: (312) 746-5254
COMPLETED BY ENGINEER / CITY / CITY ENDORSEMENT
The above material was inspected on (Date): / 29 / Inspection Report No.: / T- 32
Page 35 of
Accepted By:
(SeniorCity Forester) / 30
Approved by:
(Resident Engineer) / 31
This RFINT has been reviewed by CDOT QA and has been found to be Acceptable.
Reviewer: / 33 / Date: / 34
cc:Contractor
Resident Engineer
CDOT QA
CDOT Division Of Engineering–Eleanore Skopek / Revised 04/12

Instruction for the Request for Inspection of NURSERY TREES

This form must be completed by the Contractor and Nursery Representative, and is to be submitted by the Contractor in triplicate to the CCE. The submittal is required in a timely manner, allowing adequate time for review by the CCE and a minimum seven week lead time for the CDOT Senior Forester to review and inspect the trees at the nursery prior to delivery.

ITEMGENERAL INSTRUCTIONS

  1. City of Chicago Project Number
  2. Date that the Request for Inspection of Nursery Trees is generated
  3. Project Description
  4. IDOT Contract Number (if applicable)
  5. Consultant Resident Engineer or City of Chicago Resident Engineer (if there isn’t a Consultant Resident Engineer for the Project) and Cell Phone Number
  6. Resident Engineer E-mail Address
  7. Project Completion Date
  8. Project General Contractor
  9. Project General Contractor Address
  10. Project General Contractor Telephone and Fax Numbers
  11. Subcontractor performing the work (if applicable)
  12. Subcontractor Address (if applicable)
  13. Subcontractor Telephone and Fax Numbers (if applicable)
  14. Subcontractor e-mail address (if applicable)
  15. Contract Pay Item Number (example: 300)
  16. Pay Item Description (example: Ginko Biloba Autumn Gold, 4” Calip)
  17. Caliper(example: 4)
  18. Season of Planting (example: Fall)
  19. Quantity (example: 2)
  20. Unit of Measure (example: Each)

NURSERY CERTIFICATION – This section must be completed by the nursery prior to the contractor submitting the RFINT form to the CCE for review.

  1. The Nursery Supplying the Trees
  2. The Nursery’s Code which verifies that the Nursery is certified in their residing state.
  3. The Nursery’s Address, including street, city and state
  4. The Nursery’s Telephone Number
  5. The Nursery’s E-mail Address
  6. Signature of Nursery Representative
  7. Nursery Representative’s Printed Name
  8. Nursery Representative’s Title

CITY ENDORSEMENT– Prior to delivery, a CDOT Senior Forester must inspect and accept the trees at the nursery; then sign and date the RFINT form. After acceptance by the CDOT Senior Forester is complete, the CCE must assign a T-number to the RFINT form and sign it. The CCE shall retain one copy for the project files and forward two copies to CDOT QA with a CDOT Material Inspection Transmittal Letter attached.

  1. The Date of Inspection by the CDOTSeniorCity Forester
  2. Signature of the SeniorCity Forester
  3. Signature of the Resident Engineer
  4. RE to assign T-number in sequential order

CDOT QA ENDORSEMENT– This section is completed by CDOT QA after a thorough review of the RFINT submittal has been completed. If the documentation is in order and meets the project documentation requirements, a CDOT QA representative will sign and dates the RFINT form and return to the CCE a copy of the CDOT Materials Inspection Transmittal Letter indicating CDOT QA’s disposition. All incomplete or incorrect submittals will be returned to the CCE for revision and resubmittal.

  1. Signature of authorized CDOT QA representative.
  2. The date the RFINT form was signed by the CDOT QA representative.
  3. If creating multiple pages under a single “T” number fill in each page number sequentially and indicate the total number of RFINT pages utilized in the submittal. For single paged RFINT submittals always indicate Page 1 of 1.