Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
Date ___________________
Provisional Acceptance form
Project Name: ___________________________________________
Contractor: ___________________________________________
Client: __________________________________________________
Contract Ref No. ________________________________________
Sub City: _______________________ Consultant: ______________________
Project Type: __________________________________________
Project Location( Site):______________
This __ day of by the order of the office we the undersigned.
1. representing ____Sign__________
2. representing __________Sign_________
3. ___representing _____Sign_________
4. ___representing _____Sign_________
I. Have examined availability of:
S.No Supplementary documents Available status- Remark
Yes/No
A Pre-PA checklist and the form
B As Built drawings
C Design change checklist
D Change order checklist
Instruction
A. Pre-PA checklist and the form- to show previous remarks allowing for confirmation of rectifications
executed.
Objective of availing the As built drawing/design change and change order checklist and masonry data-
In relation to payment of variation works, the PA is used as an opportunity to obtain independent confirmation
of certain activities. Therefore the stake holders are required to check against the following:
B. As Built drawings-if it is not available at the time of PA, the contractor/Supervisor need to sketch as per the
stipulated requirement for As Built Drawings.
C.Design change checklist-to confirm the design changes applied..
D. Change order checklist-to confirm the change orders applied.
E. Quality Aspect and EIA Approval Checklist:- to confirm the weather the expected quality and service from
the project is under achieved or not.
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_________ _0478119233 Fax
Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
Remarks made during pre-PA of the works(Summary)-this will be taken from the existing
pre-PA checklist
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________
Examinations
1 Contracts, Specification and Drawings
2 Contract Amount _________________
3 The final Certificate of Measurements
4 The works and have proceeded with the temporary acceptance of the above project on the bases of the
following information.
(a) Date when the contractor took possession of site______________________
(b) Agreed length of completion time _________________________calendar days.
(Working days)
(c) Commencing date_________________
(d) Completion date according to contract_____________
(e) Actual completion date_________________________ E.C
(f) Total Number of delay ______Days(e-d)____________________
(g) Number of Justified days of delay_____Days________________
(h) Number of unjustified days of delay ________Days(f-g)_______________
(I) Penalty of ______Days(h)_____day Eth. Birr_________1/1000*2 ETB_____ Per Day Eth.
Birr______1/1000*h*2ETB________. (But shall be Max. of 10% of Contract Amount)
_________ _0478119233 Fax
Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
ACCOUNT Eth.Birr
Total Value Of Work Executed and or
material Supplied................
DEDUCTIONS Eth.Birr
1. Previous Payments...................
2. Penalty...................................
3. Rebate.....................................
4. Retention................................
5. Material Deduction.................
6. Advance Repayments.................
7. 3rd Advance Repayment.................
Total Deduction...........................
Total amount due to the Contractor……
Retention money % of the total value of work executed payable on the final
acceptance
Net Sum Payable to the Contractor_______________________________________________________
Performance Bonds _____________________________________________________________________
Remarks___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
___________________________________________________________________.
N. B. Please see the attached provisional acceptance check list for quality of work for detail remarks.
_________ _0478119233 Fax
Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
II. Examination of the works at time of Provisional Acceptance(PA)
A. Observed defects: the general examination of the works as well as
Checks and tests made at random of the different parts of the project have shown: (Refer
the attached PA check list for detail information)(use separate sheet if the space is not sufficient)
_______________________ ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
B. New orders:
New orders have been given by us to the contractor on _________ in view of making good any
eventual defects in the works: (use separate sheet if the space is not sufficient)
S.No Observed problems Due date for Rectification status checked by
rectification
_________ _0478119233 Fax
Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
IV. Decision
Complete pass Functional pass________ X _________ Fail (not PA-ed)_______
N.B.Complete pass mean the observed problems are not significant and can wait till FA. Their
rectification date is till pre-FA.
Functional Pass means that, although the Project can function, the noted magnitude of
rectifications requires the contractor to execute the rectifications requires the contractor to
execute the rectifications within the next 15 days. Failing to do so will result in with
holding 5%retention.
Fail mean the defects affect the functionality of the Project. At this stage the Project can’t be
PA-ed .If the contractor is not willing to rectify then termination issue may arise.
V. Final Decision upon rectification status (for Functional pass)
In case of Functional pass, assessment inspection occurs by Supervisor to confirm whether
remarks have been attended to within 15 days of the PA date.
Complete pass__________________ Functional pass_________________
VI. Amount to be held depending on the Final decision upon rectification status –mark on
either of the boxes.
If complete pass hold 2.5 % till FA. x
If Functional pass hold 5%till FA.
In witness thereof, we have written and signed on this form to confirm that the Project is Provisionally Accepted
on the date ________.The Final Acceptance time will be on the date __________.
Copy of this document has to be issued to the contractor, Client/ Finance/Site supervisor/City Representative/ for
all practical applications after due approval.
_____________________ ____________________ _______________
Site Supervisor Client Contractor
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_________ _0478119233 Fax
Abbaa Taayitaa የጅማ ከተማ Jimma City
Konstraakshinii ኮንስትራክሽን mERG»ን ConstructionAuthority
Magaalaa Jimma
____________________ _____
_______________ Date Date
Date
_________ _0478119233 Fax
