HomeMy WebLinkAboutCAG-20-065 - Duvall - A68 - Plants for Landscaping Washington State
V/ Department of Transportation Request for Approval of Material
Contract Number FA Number SR Date
CAG 20-065 NA Duvall Ave 8/23/2021
Section/Title of Project County
Duvall Ave NE King
Contractor Subcontractor
Reed Trucking and Excavating Green City
This form shall be completed prior to submittal. If this form is not compete at time of submittal it may For WSDOT Use Only
be returned for information that was omitted. RAM# 008
PE Use Bid item Material or Name and Location of Fabricator, Specification PE/QPL HdgtrJQPL HQ Use
No. Product/Type Manufacturer or Pit Number Reference Code Code
A68 Plant Materials J&S Nursery Sales;Hillsboro,OR 8-02.5;9-14.5(8)
8
*see attached list for plant material details*
Project Engineer/Re resentative Date State Materials Engineer/Representative Date
eptanc ction Codes for use by roject Engineer and State Materials Laboratory
1. Ac to Cri Acceptance based upon"Satisfactory"Test Report for samples of materials to be incorporated into
project.
2. Acceptance Criteria: Mfg.Cert.of Compliance for'Acceptance'prior to use of material.
3. Acceptance Criteria: Catalog Cuts for'Acceptance'prior to use of material.Catalog Cut Approved ❑Yes ❑No
4. Acceptance Criteria: Submit Shop Drawings for'Approval'prior to fabrication of material.
5. Acceptance Criteria: Only'Approved for Shipment',WSDOT Inspected'or'Fabrication Approved Decal'material shall be used.
6. Acceptance Criteria: Submit Certificate of Materials Origin to Project Engineer Office.
7. Acceptance Criteria: Request Transmitted to State Materials Laboratory for Approval Action.
OSource Approved:
9. Approval Withheld: Submit samples for preliminary evaluation.
10. Approval Withheld:
11. Miscellaneous Acceptance Criteria.
Remarks
(PE):
Remarks
(HQ):
DOT Form 350-071 Project Engineer Distribution 1�1
Revised 03/2021 I'I Contrar:tor 1 1 Reainn Oneretlnns Enaineer 1 1 Fahrinetinn InsnentInn n Raainn Materials r i State Materials Lab-MS 473R5
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waihingtonstite
Department of tra_nspottation Request for Approval of Material
Contract Number FA Number SR Date
CAG 20-065 NA Duvall Ave 8/23/2021
Section/Title of Project County
Duvall Ave NE King
Contractor Subcontractor
Reed Trucking and Excavating Green City
This form shall be completed prior to submittal. If this form is not compete at time of submittal it may For WSDOT Use Only
be returned for information that was omitted. RAM# 008
PE Use Bid Item Material or Name and Location of Fabricator, Specification PE/QPL Hdgtr./QPL HQ Use
No. Product/Type Manufacturer or Pit Number Reference Code Code
A68 Plant Materials J&S Nursery Sales;Hillsboro,OR 8-02.5;9-14.5(8) 8
L
*see attached list for plant material details*
Project Engineer/Representative Date State Materials Engineer/Representative Date
Acceptance Action Codes for use by Project Engineer and State Materials Laboratory
1. Acceptance Criteria: Acceptance based upon"Satisfactory"Test Report for samples of materials to be incorporated into
project.
2. Acceptance Criteria: Mfg.Cert.of Compliance for'Acceptance'prior to use of material.
3. Acceptance Criteria: Catalog Cuts for'Acceptance'prior to use of material.Catalog Cut Approved ❑Yes ❑No
4. Acceptance Criteria: Submit Shop Drawings for'Approval'prior to fabrication of material.
5. Acceptance Criteria: Only'Approved for Shipment','WSDOT Inspected'or'Fabrication Approved Decal'material shall be used.
6. Acceptance Criteria: Submit Certificate of Materials Origin to Project Engineer Office.
7. Acceptance Criteria: Request Transmitted to State Materials Laboratory for Approval Action.
8. Source Approved:
9. Approval Withheld: Submit samples for preliminary evaluation.
10. Approval Withheld:
11. Miscellaneous Acceptance Criteria.
Remarks
(PE):
Remarks
(HQ):
DOT Form 350-071 Project Engineer Distribution
Revised 03/2021 Iva Contractor ❑Region Operations Engineer ❑Fabrication Inspection Region Materials ❑State Materials Lab-MS 47365
Project: Duvall Ave NE
Est Planting Date: November 2021
Botanical Name Common Name Size Spacing QTV Notes
Cornus Nutalli x Kousa 'Starlight' Starlight Dogwood 2" cal, 12-14' ht 25'OC 44
Magnolia Stellata Star Magnolia 2" cal, 12-14' ht per plan 13
Cornus Sericea 'Kelseyii' Kelseyii Dogwood 1 gal 2'OC 884
Erica x Darleyensis'Mediterranean P Mediterranean Pink Heath 1 gal 18"OC 1135
Hemerocallis'Stella D'Oro' Stella D'Oro Daylily 1 gal 2' OC 270
Miscanthus Sinesis'Dixieland' Variegated Maiden Grass 2 gal 4'OC 160
Potentilla Fruiticosa 'Abbotswood' Abbotswood Potentilla 3 gal 2' OC 29
Prunus Laurocerasus'Mt.Vernon' Mt Vernon Laurel 1 gal 12" OC 1555
AMENDED ANNUAL REPORT
E-FILED
Corporation Division
Mar 02, 2021
www.filinginoregon.com OREGON SECRETARY OF STATE
„o
REGISTRY NUMBER
131350993
REGISTRATION DATE Engineer's Addition
04/11/2017
BUSINESS NAME
J & S NURSERY LLC
BUSINESS ACTIVITY
PLANT NURSERY/PLANT BROKER
MAILING ADDRESS
515 BUCKLEY LN
NEWBERG OR 97132 USA
TYPE
DOMESTIC LIMITED LIABILITY COMPANY
PRIMARY PLACE OF BUSINESS
515 BUCKLEY LN
NEWBERG OR 97132 USA
JURISDICTION
OREGON
REGISTERED AGENT
STEVE GRACE
515 BUCKLEY LN
NEWBERG OR 97132 USA
If the Registered Agent has changed,the new agent has consented to the appointment.
MEMBER
STEVE GRACE
515 BUCKLEY LN
NEWBERG OR 97132 USA
MEMBER
JANET GRACE
515 BUCKLEY LN
NEWBERG OR 97132 USA
Page 1
A
= Engineer's Addition
...If*; Corporation Division
• , www.filinginoregon.com
OREGON SECRETARY OF STATE
!1i
I declare, under penalty of perjury, that this document does not fraudulently conceal, fraudulently obscure,
fraudulently alter or otherwise misrepresent the identity of the person or any officers, managers, members or
agents of the limited liability company on behalf of which the person signs. This filing has been examined by me
and is,to the best of my knowledge and belief,true, correct, and complete. Making false statements in this
document is against the law and may be penalized by fines, imprisonment, or both.
By typing my name in the electronic signature field, I am agreeing to conduct business electronically with the
State of Oregon. I understand that transactions and/or signatures in records may not be denied legal effect solely
because they are conducted, executed, or prepared in electronic form and that if a law requires a record or
signature to be in writing, an electronic record or signature satisfies that requirement.
ELECTRONIC SIGNATURE
NAME
MEMBER
TITLE
STEVE GRACE
DATE SIGNED
03-02-2021
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