Ph lc C

(qui nh)

Mu bin bn nghim thu u vo

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
----------------a im, ngy.......... thng......... nm..........

BIN BN S .................
NGHIM THU VT LIU, THIT B, SN PHM CH TO SN TRC KHI S
DNG

Cng
trnh
.................................................(ghi
dng)...............................................
Hng mc: ...................................................(ghi
dng)...........................

tn

tn
hng

cng
mc

trnh
cng

trnh

xy
xy

a im xy dng: .......(ghi r a im xy dng hng mc cng trnh v cng trnh xy

dng)........
1. i tng nghim thu: (ghi r tn vt liu, thit b, sn phm ch to sn cn
nghim thu )

2. Thnh phn trc tip tham gia nghim thu: (Ghi r t chc, h tn v chc
v c nhn)
-

Ngi gim st thi cng xy dng cng trnh ca ch u t hoc ngi

gim st thi cng xy dng cng trnh ca Tng thu i vi hnh thc
hp ng tng thu ;

Ngi ph trch k thut thi cng trc tip ca nh thu thi cng xy
dng cng trnh.

Trong trng hp hp ng tng thu, ngi gim st thi cng xy dng

cng trnh ca ch u t tham d kim tra cng tc nghim thu ca tng
thu vi nh thu ph.
3. Thi gian nghim thu :
Bt u :

.......... ngy.......... thng......... nm..........

Kt thc :

........... ngy.......... thng......... nm..........

Ti: ...........................

4. nh gi cng vic xy dng thc hin:

a) V ti liu lm cn c nghim thu
-

Phiu yu cu nghim thu ca nh thu thi cng xy dng;

H s thit k bn v thi cng c ch u t ph duyt v nhng thay

i thit k c chp thun: (Ghi r tn cc bn v thit k c lin
quan n i tng nghim thu)

Tiu chun, quy phm xy dng c p dng: (Ghi r tn tiu chun,

qui phm, ti liu ch dn k thut chuyn mn c lin quan n i
tng nghim thu)

H s thu v hp ng xy dng;

H s xut x, Chng ch k thut xut xng, kt qu th nghim mu

kim nghim cht lng;

Danh mc tnh nng k thut ca cc i tng nghim thu;

Nht k thi cng, nht k gim st ca ch u t v cc vn bn khc

c lin quan n i tng nghim thu;

Bin bn nghim thu ni b i tng nghim thu;

b) V cht lng vt liu, thit b, sn phm ch to sn: (i chiu vi thit

k, tiu chun, qui phm k thut, ti liu ch dn k thut chuyn mn v

yu cu k thut ca cng trnh xy dng c lin quan n i tng

nghim thu:
-

a ra cc ni dung k thut cn kim tra khi nghim thu c c s

nh gi cht lng i tng nghim thu;

Thc hin cng tc nghim thu nh qui nh iu 4.1 tiu chun ny;

nh gi cht lng i tng nghim thu)

c) Cc kin khc nu c.

5. Kt lun : (ghi r theo cc ni dung sau)

-

Chp nhn hay khng chp nhn nghim thu, ng hay khng ng a
vo s dng cho cng trnh i tng nghim thu. Nu khng chp nhn
nghim thu phi ghi r l do,

Ghi r tn v s lng cc i tng khng chp nhn nghim thu. Thi

gian nh thu xy lp phi a cc i tng khng chp nhn nghim thu
ra khi cng trng.

6. Cc thnh phn trc tip tham gia nghim thu:(K, ghi r h tn v chc v
tng ngi tham gia)

H s nghim thu bao gm:

-

Bin bn nghim thu vt liu, thit b, sn phm ch to sn trc khi s

dng v cc ph lc km theo nu c;

Cc ti liu lm cn c nghim thu.