Form CEM-4902 "Extra Work Bill (Short Form)" - California

What Is Form CEM-4902?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 1994;
  • The latest edition provided by the California 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 CEM-4902 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form CEM-4902 "Extra Work Bill (Short Form)" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
EXTRA WORK BILL (SHORT FORM)
ADA Notice
CEM-4902
(REV 7/1994)
CT# 7541-3500-8
For individuals with sensory disabilities, this document is available in alternate
CONTRACT NO.
CCO NO.
REPORT NO.
formats.
For information call (916) 654-6410 or TDD (916) 654-3880 or write
Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
E.W.
A.C.
BR
*50%
SUB
R/W
PARTNERING
LABOR
WCI CLASS
WCI RATE
DATE PERFORMED
DATE OF REPORT
CONTRACTOR. JOB
CONTRACTOR. RPT. NO.
+ -
FA
LS
UP
FA
LS
UP
SW
FLAG
WORK
DELAY
SWITCH
SUR
01
WORK PERFORMED BY
02
DESCRIPTION OF WORK
03
EQUIPMENT CHARGES
EQUIPMENT DESCRIPTION
REGULAR
OVERTIME
EQUIPMENT ID NUMBER
FOR RESIDENT ENGINEERS ONLY
HOURS
HOURS
CLASS
MAKE
CODE
ATTACH
04
NEW BILL
APPROVED FOR
PAYMENT
05
RESUBMITTAL
RETURNED FOR
06
CORRECTION
DATE RECEIVED
DATE OF ACTION
07
08
09
10
MATERIAL and/or WORK DONE BY SPECIALIST OR LUMP OR UNIT PRICE PAYMENTS
VENDOR NAME
INVOICE NUMBER
MO
DAY
YR
24
INVOICE DESCRIPTION
UNITS
UNIT COST OR NET PAY
VENDOR NAME
INVOICE NUMBER
MO
DAY
YR
25
INVOICE DESCRIPTION
UNITS
UNIT COST OR NET PAY
LABOR CHARGES
LABOR NAME
LABOR REGULAR HOURS
OVERTIME HOURS
SUBSISTENCE
CRAFT ID
INT
LAST
HRS
RATE
HRS
RATE
UNITS
RATE
34
35
36
37
38
39
40
SIGNATURE OF RESIDENT ENGINEER
IN CASE OF QUESTIONS CONTACT: (Resident Engineers Use Only)
SIGNATURE OF PRIME CONTRACTORS REPRESENTATIVE
NAME
BUSINESS PHONE
FM 94 2020 M
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
EXTRA WORK BILL (SHORT FORM)
ADA Notice
CEM-4902
(REV 7/1994)
CT# 7541-3500-8
For individuals with sensory disabilities, this document is available in alternate
CONTRACT NO.
CCO NO.
REPORT NO.
formats.
For information call (916) 654-6410 or TDD (916) 654-3880 or write
Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
E.W.
A.C.
BR
*50%
SUB
R/W
PARTNERING
LABOR
WCI CLASS
WCI RATE
DATE PERFORMED
DATE OF REPORT
CONTRACTOR. JOB
CONTRACTOR. RPT. NO.
+ -
FA
LS
UP
FA
LS
UP
SW
FLAG
WORK
DELAY
SWITCH
SUR
01
WORK PERFORMED BY
02
DESCRIPTION OF WORK
03
EQUIPMENT CHARGES
EQUIPMENT DESCRIPTION
REGULAR
OVERTIME
EQUIPMENT ID NUMBER
FOR RESIDENT ENGINEERS ONLY
HOURS
HOURS
CLASS
MAKE
CODE
ATTACH
04
NEW BILL
APPROVED FOR
PAYMENT
05
RESUBMITTAL
RETURNED FOR
06
CORRECTION
DATE RECEIVED
DATE OF ACTION
07
08
09
10
MATERIAL and/or WORK DONE BY SPECIALIST OR LUMP OR UNIT PRICE PAYMENTS
VENDOR NAME
INVOICE NUMBER
MO
DAY
YR
24
INVOICE DESCRIPTION
UNITS
UNIT COST OR NET PAY
VENDOR NAME
INVOICE NUMBER
MO
DAY
YR
25
INVOICE DESCRIPTION
UNITS
UNIT COST OR NET PAY
LABOR CHARGES
LABOR NAME
LABOR REGULAR HOURS
OVERTIME HOURS
SUBSISTENCE
CRAFT ID
INT
LAST
HRS
RATE
HRS
RATE
UNITS
RATE
34
35
36
37
38
39
40
SIGNATURE OF RESIDENT ENGINEER
IN CASE OF QUESTIONS CONTACT: (Resident Engineers Use Only)
SIGNATURE OF PRIME CONTRACTORS REPRESENTATIVE
NAME
BUSINESS PHONE
FM 94 2020 M
EXTRA WORK BILL (SHORT FORM)
CEM-4902
(REV 7/1994)
CT# 7541-3500-8
Preparing Form CEM 4902
This form is provided for entry of basic information related to extra work performed on a Contract Change Order. The majority of all Extra Work Bills will fit on this form. If more
entries are required for equipment, labor or material, you must use the four part forms. (CEM-4902A, CEM-4902B, CEM-4902C, CEM-4902D)
The top of this form includes fields that are used to record basic information required on all Extra Work Bills. Following is a list of these fields: All switch fields, Bridge, flagging,
sub work, R/W Delay and Partnering are set by entering a "Y" in the appropriate box. To remove a switch from an existing bill, place an "N" in the appropriate box.
FIELD
REMARKS
Contract Number
Identifies the project. Must be a valid contract number that is on file in the Progress Pay System.
CCO Number
Identifies the Contract Change Order.
Report Number
This is assigned by the submitter (R.E.), in sequential order beginning with 0001 for each CCO.
Line 01:
Date Performed
Enter the work performed date. "VAR" may be entered in this field if the pay method is lump-sum or unit-price and equipment.
Date of Report
Enter the date the bill is prepared.
Contractor. Job No.
This is used by the contractor to identify the extra work bill.
Contractor. Rpt. No.
This is used by the contractor to identify the extra work bill.
Payment Method
Required entry. Indicate + or -, and place an "X" in the appropriate box. A blank is considered a +.
BR SW
Set to "Y" in if the CCO indicates work on structure items.
50% Flag
Set to "Y" if the bill is for flagging. This will reduce the bill by 50%.
Sub Work
Set to "Y" to add subcontractor markup.
R/W Delay
Set to "Y" if bill is for right of way delay. No markup will be applied to the bill.
Partnering Switch
Set to "Y" if bill is for partnering. No markup will be applied to the bill.
Labor Sur
Enter the labor surcharge for the type of work normally performed by that contractor.
Line 02 and 03
Work Performed By
Identify the party that is performing the work.
Description of Work
Identify the location and description of the work.
Lines 04 -10 Equipment Charges
Equipment Description
Enter equipment ID, Class, Make, Code. If any are missing the bill will not be accepted.
Equipment Attachments
Enter attachment codes.
Equipment Hours
Enter regular and overtime hours. Hours must be greater than zero.
Lines 24 -25 Materials and/or Work done by Specialist or Lump or Unit Price Payments
Vendor Name
Enter the vendor's name.
Invoice data
Enter the invoice number, date, and description.
Invoice units & cost
Enter the number of units and the unit cost or net pay.
Lines 34 - 40 Labor Charges
Labor Description
Enter labor craft, initial and last name.
Labor Hours & Rate
Enter regular and overtime hours and rates. Hours and rates must not be zero.
Subsistence
Enter subsistence hours and rate if subsistence was paid.
CEM4902
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