Ph lc D

(qui nh)

Mu bin bn nghim thu cng vic xy dng

CNG HO X HI CH NGHA VIT NAM

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

BIN BN S ...........................
NGHIM THU CNG VIC XY DNG

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

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 cng vic hon thnh cn nghim thu
v v tr nm trong hng mc hoc cng trnh)
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;

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

dng;

Cc ti liu th nghim, quan trc, kt qu th nghim mu kim nghim

ca i tng nghim thu (nu thit k hoc tiu chun, qui phm c
lin quan yu cu)

Bn v hon cng;

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 cng vic xy dng: (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 c c s nh gi cht

lng cn nghim thu;

Thc hin cng tc nghim thu nh qui nh iu 4.2 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
cho trin khai cc cng vic xy dng tip theo. Nu khng chp nhn
nghim thu th ghi r l do.

Cc sai st cn tn ti v cc khim khuyt cn sa cha. Thi gian nh

thu phi hon thnh cng tc sa cha.

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 cng vic xy dng gm:

-

Bin bn nghim thu cng vic xy dng v cc ph lc km theo nu

c;

Cc ti liu lm cn c nghim thu.