SUBJECT: EXPERIENCE DETAILS FOR PIPELINE LAYING
(For Applicability Mark Ö and Non Applicability Mark X in ).
SL.NO. / SUBJECT / DETAILS /
1.0 / Name of Work
2.0 / Details of Client/ Consultant / CLIENT / CONSULTANT
2.1 / Name
2.2 / Name of Officer Incharge, Design
2.3 / Postal Address
2.4 / Phone, Fax, e-mail / Phone______
Fax ______
e-mail______/ Phone______
Fax ______
e-mail______
3.0 / Name of Work
3.1 / Scope
3.2 / Contract Value / Awarded -
Executed -
3.3 / Time Schedule / Date of Award of Work -
Time Schedule - Months
Schedule Date of Completion -
Actual Date of Completion -
4.0 / Details of Pipeline:- / A.
Dia./ Size of Pipeline / Length in KM. / Service
B. No. of Crossings:-
* River Crossings - ……………… Nos.(HDD/Open cut)
* Rail Crossings - ……………… Nos. (HDD/Open cut)
* Road Crossings - ……………… Nos. (HDD/Open cut)
* Any other Crossing - (Specify type and Nos.)
NOTE : Tick as applicable. In case all crossings of one type are not carried out by one method i.e. HDD or open cut please elaborate separately.
C. Your Scope of work for this Contract:-
- Design and Engg. Radiography
- Procurement and Supply Pigging
- Coating/Wrapping Commissioning
- Transportation Trenching
- Laying Hydrotesting
- Crossings
5.0 / Details of Sub-Contractor / Furnish Details of Sub-Contractor engaged in this work
Sl. No. / Name / Services
1.
2.
3.
4.
5.
6.
7.
6.0 / Mechanical Completion and Commissioning / (i) Date of Mechanical Completion -
(ii) Date of Commissioning -
7.0 / Documentary Supports / Confirm that following documents have been submitted :
(a) Copy of Work Order and/or relevant pages of Contract document mentioning scope of work, contract value, time schedule, all technical details as per Sl.No.4.0 above.
YES NO
(b) Completion Certificate - YES NO
(c) Performance Certificate - YES NO
Certificate
8.0 / Miscellaneous Details / Enclose List of Construction Eqpts. deployed by you for this work as Annexure-‘A’.
Bidder’s Name ______
Name and Designation of Signatory ______Signature with Date ______
TC-Form-22 1 of 3