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UNITATEA __________________________________________________________________

ANEXA 4

CONTRACT NR. ___________________________________________________________

SANTIER ______________________ PUNCT DE LUCRU________________________

OBIECTIVUL ____________________________________________________________

PROCES VERBAL DE PREDARE AMPLASAMENT

_____________________________________________

Nr. _______ / Data___________

Denumirea obiectivului (lucrarii)

_________________________________________________________________________________

Predarea a fost executata de

_________________________________________________________________________________

Pe baza planselor nr. _______________________________________________________________

din proiectul ______________________________________________________________________Elementul de reper si verificare (borna, constructie invecinata, etc...) __________________________________________________________________________________________________________________________________________________________________

avand coordonatele:Borna 1

Borna 2

Borna 3

X___________________ X_________________ X_______________

Y___________________

Y_________________ Y_______________

Z ___________________ Z_________________ Z_______________

Constructii / instalatii existente la suprafata amplasamentului sau subteran:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Participanti: Nume:

Prenume:

Semnatura

Beneficiar Primarie

__________

_________________________Beneficiar ACET

__________

_________________________Inginer

__________

_________________________

Proiectant __________

_________________________Executant