QES Management System

Issue Date: 01/07/2014

Constructed verification form

To be lodged by the consultant

City West Water

Email

Service(please select)

Water supply Recycled water Sewerage Pump station

Development details

Location/estate name:
City West Water reference:
Developer:
Consultant:
Contractor:
Consultant nominated representative:
Contractor nominated representative:
Consultant key personnel – Construction Auditor:
Contractorkey personnel – Construction Supervisor:

1Documentation to be submitted (please select):

1.1evidence that the application to amend the plan of subdivision for the creation of additional easements has been lodged
with council

1.2relevant As-constructed Verification Form and as-constructed information

1.3chlorination Completion Certificate in accordance with Clause 1.8.7 of City West Water’s Land Development Manual, if
chlorination of main was required

1.4water quality testing results for all mains less than 225mm in diameter in accordance with Clause 1.8.7 of City West Water’s LandDevelopment Manual

1.5compaction test results in accordance with Clause 1.8.9 of City West Water’s Land Development Manual

1.6works warranty bond in accordance with Clause 3.1.9 of City West Water’s Land Development Manual

1.7Verification Attachment Sheet, if any of the items on this form are not applicable.

2Consultant’s assurance

As the Consultant’s nominated representative responsible for the project management
of the development works detailed in the Development Deed, City West Water reference:

I verify that:

2.1the as-constructed development works meet:

  • the scope and requirements of the Development Deed
  • the design intent and is fit for purpose
  • relevant WSAA/City West Water specifications and requirements.
  1. the audit schedule has been satisfactorily undertaken by the construction auditor
  2. all non-conformances have been satisfactorily resolved and corrective action implemented.

Consultant’s nominated representative

Name: / Company position:
Signature: / Date:

3Contractor’s assurance

As the Consultant’s nominated representative responsible for the project management
of the development works detailed in the Development Deed, City West Water reference:

I verify that:

3.1the development works have been constructed in accordance with the requirements of the Development Deed and its referreddocuments and standards

3.2the development works have been satisfactorily supervised by the construction supervisor.

3.3all non-conformances have been satisfactorily resolved and corrective action implemented.

Contractor’s nominated representative

Name: / Company position:
Signature: / Date:

Important privacy notice

City West Water is a state owned company which provides retail water, sewerage and trade waste services to Melbourne’s central business district, inner and western suburbs.

By completing this form you are providing personal information to City West Water for the primary purpose of City West Water providing you with a water or sewerage supply. To read City West Water’s complete privacy statement, please visit citywestwater.com.au

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