M· sè BM:11.

03
TỔNG CÔNG TY LILAMA VIỆT NAM
LÇn ban hµnh 01
CÔNG TY CỔ PHẦN LILAMA 3
Ngµy ban hµnh 15/9/2008

............Ngµy...........th¸ng....... n¨m.........

biªn b¶n NghiÖm thu vËt t ®a vµo sö dông

Biªn b¶n sè: ………

C«ng tr×nh : ................................................................................................................

Gãi thÇu:..........................................................................................................................
H¹ng môc:........................................................................................................................
I - §èi tîng nghiÖm thu :
VËt t chÕ t¹o: H¹ng môc:..
II- Thµnh phÇn trùc tiÕp nghiÖm thu :
§¹i diÖn Chñ ®Çu t:
¤ng: ...................................... Chøc vô: ...........................
¤ng: ...................................... Chøc vô: ...........................
¤ng...................................... Chøc vô: ...........................

 §¹i diÖn t vÊn gi¸m s¸t:.

¤ng: ...................................... Chøc vô: ...........................
¤ng: ...................................... Chøc vô: ...........................
¤ng...................................... Chøc vô: ...........................

 §¹i diÖn t vÊn thiÕt kÕ (nÕu cã) :

¤ng: ...................................... Chøc vô: ...........................
¤ng: ...................................... Chøc vô: ...........................
¤ng...................................... Chøc vô: ...........................
 §¹i diÖn Nhµ thÇu thi c«ng:
¤ng: ...................................... Chøc vô: ...........................
¤ng: ...................................... Chøc vô: ...........................
¤ng...................................... Chøc vô: ...........................
III - Thêi gian nghiÖm thu:
B¾t ®Çu.............................. Ngµy................ Th¸ng............ N¨m................
KÕt thóc.......................... Ngµy................ Th¸ng............ N¨m................
§Þa ®iÓm
IV - ®¸nh gi¸ khèi lîng, c«ng viÖc ®· thùc hiÖn :

1. Xem xÐt c¸c hå s¬, tµi liÖu sau:

 GiÊy mêi kiÓm tra lÊy mÉu, nghiÖm thu vËt t
 Hå s¬ tµi liÖu thiÕt kÕ:
.............................................................................................................................................................
………………………………………………………………………………................................................
 Tiªu chuÈn kü thuËt ¸p dông khi thi c«ng, kiÓm tra vµ nghiÖm thu
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 C¸c chøng chØ liªn quan:
§¬n vÞ Sè lîng Chøng chØ M¸c
Sè TT M« t¶ vËt t Sè nguån Sè chøng
cña CQ chøc
gèc vËt t chØ chÊt l-
n¨ng
îng
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

 C¸c biªn b¶n liªn quan:

 Biªn b¶n kiÓm tra hiÖn trêng.
2. NhËn xÐt chÊt lîng, khèi lîng ®· thùc hiÖn:
 VÒ chÊt lîng vËt t thi c«ng so víi thiÕt kÕ ®îc duyÖt
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 Khèi lîng thùc hiÖn(kg):…………………….Kg
(B»ng ch÷: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . )

3. Nh÷ng söa ®æi so víi thiÕt kÕ ®· ®îc phª duyÖt:

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4. ý kiÕn cña T vÊn gi¸m s¸t.
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V - KÕt luËn:
 §ång ý hay kh«ng ®ång ý nghiÖm thu vËt t ®Ó ®a vµo sö dông.
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X¸c nhËn cña c¸c bªn.(Ký vµ ghi râ hä tªn, chøc vô)

§¹i diÖn chñ ®Çu t §¹i diÖn t vÊn gi¸m s¸t

T vÊn thiÕt kÕ (nÕu cã) §¹i diÖn nhµ thÇu