F070 02 AgencyLocalAdministrationRequest by GY53Q45

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									Local Administration Request
State of Ohio Standard Forms and Documents

Agency/Institution                                        Date                                      Sheet       1         of
Agency Designee*                                          Project Funding                           Project Type
Owner Representative                                      State Funds       $                           Addition
Address 1                                                 Local Funds       $                           Infrastructure
Address 2                                                 Other Funds       $                           Landscape/Sitescape
City, State, ZIP                                            Describe                                    New Construction
Phone Number                                              Total Budget      $                           Renovation
Fax Number                                                House Bill No.                                Percent for Art
E-mail Address                                            Cap Line No.                                  Study
Federal Tax ID No.                                        No. of floors (including basement)
House Bill No.                                            Gross Square Footage
Cap Line No.
Project Number                                            Estimated Ohio Register advertisement date (mm/yy)               /
Project Name                                              Estimated construction completion date (mm/yy)                   /
Project Location                                          Estimated construction duration (no. of months)
Project Description




Key Project Staff Assignment (provide names and titles)




F070-01v0912                                                                                                                   Page 1 of 5
Local Administration Request
State of Ohio Standard Forms and Documents


Project Number                                                                                                                                           Sheet              2         of

Project Name                                                                                                                                             Date

Personnel by Discipline or Staff Function
List each person only once, by primary function. List only those who are under the direct supervision of the Owner Representative*. A Project Manager is defined as the
designated employee who is assigned to the Project to consult with the Architect/Engineer. Attach a Table of Organization showing all individuals listed below.

      Administrative ..................................... (      are Project Managers)          Soils Engineers .............................................. (          are Project Managers)

      Architects ............................................ (   are Project Managers)          Specification Writers ...................................... (            are Project Managers)

      Business Managers ............................ (            are Project Managers)          Structural Engineers....................................... (             are Project Managers)

      CADD Operators ................................. (          are Project Managers)          Surveyors ....................................................... (       are Project Managers)

      Civil Engineers .................................... (      are Project Managers)          Transportation Engineers ............................... (                are Project Managers)

      Construction Inspectors ...................... (            are Project Managers)   Other(s):

      Electrical Engineers ............................ (         are Project Managers)                    .......................................................... (   are Project Managers)

      Environmental Health & Safety ........... (                 are Project Managers)                    .......................................................... (   are Project Managers)

      Field Construction Officers .................. (            are Project Managers)                    .......................................................... (   are Project Managers)

      Fiscal Officers ..................................... (     are Project Managers)                    .......................................................... (   are Project Managers)

      Fiscal Assistants ................................. (       are Project Managers)                    .......................................................... (   are Project Managers)

      Interior Designers................................ (        are Project Managers)                    .......................................................... (   are Project Managers)

      Landscape Architects .......................... (           are Project Managers)                    .......................................................... (   are Project Managers)

      Mechanical Engineers ......................... (            are Project Managers)                    .......................................................... (   are Project Managers)

      Planners: Urban / Regional ................. (              are Project Managers)                    .......................................................... (   are Project Managers)

      Sanitary Engineers.............................. (          are Project Managers)                    .......................................................... (   are Project Managers)




F070-01v0912                                                                                                                                                                               Page 2 of 5
Local Administration Request
State of Ohio Standard Forms and Documents


Project Number                                                                                                                      Sheet           3          of

Project Name                                                                                                                        Date

Discipline or Staff Function Descriptions
Complete the following for each staff function (discipline) listed in the “Personnel by Discipline or Staff Function” section of this form. Use additional pages as necessary.

      Discipline:
      Describe Duties:




      Discipline:
      Describe Duties:




      Discipline:
      Describe Duties:




F070-01v0912                                                                                                                                                         Page 3 of 5
Local Administration Request
State of Ohio Standard Forms and Documents

Project Number                                                                                                               Sheet                     of

Project Name                                                                                                                 Date

Resumes
Use this sheet to provide a brief resume of all personnel, including Owner Representative, shown on Table of Organization. Use a separate page for each employee.

     Name and Discipline or Staff Function

     Name of Office with which Associated

     Years of Experience                                     With this Institution               With other organizations

     Education                                     Degree                                 Year            Specialization

                                                   Degree                                 Year            Specialization

     Active Registration(s)                        Year first registered                  Discipline

                                                   Year first registered                  Discipline

     Certifications and Licenses
     Experience and Qualifications




F070-01v0912                                                                                                                                                Page 4 of 5
Local Administration Request
State of Ohio Standard Forms and Documents


Project Number                                                                                                                    Sheet                      of

Project Name                                                                                                                      Date

Local Administration Experience / Workload
This information is used to analyze applicant’s work experience and current workload. List all projects in progress that are being locally administered.

Project Specific Information                                                             Project Funding                                   Project Type
Project Number                                                                           State Funds         $                                  Addition
Project Name                                                                             Local Funds         $                                  Infrastructure
                                                                                         Other Funds         $                                  Landscape/Sitescape
Project Location                                                                            Describe                                            New Construction
Anticipated Ohio Register advertising date (mm/yy)               /                       Total Budget        $                                  Renovation
Estimated construction completion date (mm/yy)                   /                       House Bill No.                                         Percent for Art
Anticipated construction duration (no. of months)                                        Cap Line No.                                           Study
Project Description
                                                                                                                         No. of floors (including basement)
                                                                                                                         Gross Square Footage




Key Project Staff Assignment (indicate names and titles below)




F070-01v0912                                                                                                                                                       Page 5 of 5

								
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