Form 700-010-12 "Utility Conflict and Damage Report" - Florida

What Is Form 700-010-12?

This is a legal form that was released by the Florida Department of Transportation - a government authority operating within Florida. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on April 1, 2018;
  • The latest edition provided by the Florida Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 700-010-12 by clicking the link below or browse more documents and templates provided by the Florida Department of Transportation.

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Download Form 700-010-12 "Utility Conflict and Damage Report" - Florida

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700-010-12
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
CONSTRUCTION
UTILITY CONFLICT AND DAMAGE REPORT
04/18
Complete as much as possible
Financial
Beginning
Ending
Contract
State Road
Project No. or
County
Section No.
Station or Mile
Station or Mile
No.
No.
Permit No.
Post
Post
General description of contract work:
Part A – Contractor or Agency Involved
Contractor/Agency Information:
Select One
Name:
Address:
Contact Person:
Phone Number:
Address of Damaged Facility:
Part B – Facility Damaged (provide digital photographs)
Date and Time Damage Occurred
Date and Time Damage Repaired
Duration of Outage
If other describe here:
Type of Facility Damaged:
If other describe here:
Type of Facility Material Damaged:
Location of damaged Facility:
If other describe here:
Roadway
Direction
The facility is -
If other describe here:
Measurements and dimensions of facility damaged:
Station No.
Height
Depth
Length
Elevation
Diameter
Offset from C.L. of Construction
Additional description here:
Part C – Locating and Marking
If Yes, provide date, time, and Sunshine 811 Locate No. here:
Did the contractor request a locate?
Yes
No
If other describe here:
Type of locate used:
Did contractor verify all utilities were cleared through the Positive Response System of Sunshine811?
Yes
No
Was the facility located prior to being encountered?
Yes
No
Provide any additional locate information here:
Page 1 of 2
700-010-12
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
CONSTRUCTION
UTILITY CONFLICT AND DAMAGE REPORT
04/18
Complete as much as possible
Financial
Beginning
Ending
Contract
State Road
Project No. or
County
Section No.
Station or Mile
Station or Mile
No.
No.
Permit No.
Post
Post
General description of contract work:
Part A – Contractor or Agency Involved
Contractor/Agency Information:
Select One
Name:
Address:
Contact Person:
Phone Number:
Address of Damaged Facility:
Part B – Facility Damaged (provide digital photographs)
Date and Time Damage Occurred
Date and Time Damage Repaired
Duration of Outage
If other describe here:
Type of Facility Damaged:
If other describe here:
Type of Facility Material Damaged:
Location of damaged Facility:
If other describe here:
Roadway
Direction
The facility is -
If other describe here:
Measurements and dimensions of facility damaged:
Station No.
Height
Depth
Length
Elevation
Diameter
Offset from C.L. of Construction
Additional description here:
Part C – Locating and Marking
If Yes, provide date, time, and Sunshine 811 Locate No. here:
Did the contractor request a locate?
Yes
No
If other describe here:
Type of locate used:
Did contractor verify all utilities were cleared through the Positive Response System of Sunshine811?
Yes
No
Was the facility located prior to being encountered?
Yes
No
Provide any additional locate information here:
Page 1 of 2
700-010-12
STATE OF FLORIDA DEPARTMENT OF TRANSPORTATION
CONSTRUCTION
UTILITY CONFLICT AND DAMAGE REPORT
04/18
Part D – Answer the following questions. (place a check in the column under Yes or No)
YES
NO
1)
Was the facility in the subgrade area?
2)
Was the facility in the base area?
3)
Was the facility within 12 inches below the bottom of the stabilized subgrade?
4)
Was the facility shown on the construction plans? If Yes, provide Sheet No.
5)
Did the construction plans accurately illustrate the field conditions?
6)
Was the utility in conduit or carrier pipe?
7)
Did the contractor/agency attempt to locate the facility?
8)
If the facility was located, did the contractor/agency encounter it within two (2) feet horizontally
on either side of the utility markings?
9)
Did the contractor/agency immediately notify the facility owner of the incident?
a. Utility Owner -
b. Utility Representative -
i. Office Phone No. -
ii. Cell Phone No. -
10)
Did this impede the contractor’s/agency’s intended work? If Yes, provide time -
11)
If damage occurred during a Construction Project, was there a Utility Work Schedule (UWS)?
12)
Was the utility facility discussed during a Pre-Construction or Progress Meeting(s) prior to being
damaged or being found to be in conflict?
13)
If the facility was parallel to the roadway, was the depth 30” or more below existing grade?
If no, what was the depth?
14)
If the facility was underneath paved roadway, was the depth 36” or more below the top of the
paved surface? If no, what was the depth?
Describe what happened:
Describe how the problem was solved:
Describe the extent of the delay to the Contractor or Agency:
Print Name:
Title:
Signature:
Date:
Distribution:
Distribution List:
Project Administrator
District Construction Engineer
Contractor
Utility
District Utility Coordinator
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