The UNIVERSITY of CALIFORNIA-[insert campus] hereby requests PWB / DOF action related to the following project:

1. Project ID: [insert CFIS ID#] Project Title: [insert full project title]

2. Requested PWB/DOF Action Date: [insert date] Date of last approval: [insert date]

3. Requested Action: (all reporting requirements related to this request as defined in SAM, are attached)
____ Site Acquisition - Section 6848 (an agenda package has been submitted to DGS)
____ Approve Preliminary Plans - Section 6851
____ Approve Working Drawings - Section 6852
____ Approve Proceed to Bid - Section 6852
____ Approve Construction Contract Award - Section 6853
____ Request for Augmentation / Reversion - Section 6861, 6862
____ Approve Scope Change - Section 6863
____ Other, Specify:____________________________________________________________________

4. Project Completion Reporting: (reporting requirements as defined in Section 6856 are attached)
____ Project Occupancy
____ Project Completion
____ Project Close-out

5. Project Certifications:
CEQA Compliance: (reporting requirements as defined in Section 6850 are attached)
____ This project meets CEQA compliance requirements.
____ The action requested does not invalidate the CEQA compliance.
____ The action requested mandated a review of the CEQA compliance.
Scope Changes: (reporting requirements as defined in Section 6863 are attached)
____ Project scope has not changed from that as defined in the previous reporting.
____ A change in project scope is necessary in order to proceed with the project.
Costs/Funding/Schedule Changes: (reporting requirements as defined in Section 6861 are attached)
____ Costs, funding, and schedules have not changed from that as defined in the previous reporting.
____ Changes in cost, funding and/or schedules are necessary in order to proceed with the project.

I hereby certify that the above is accurate and that the necessary reporting requirements as defined in SAM are included with this request.

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RESULTING ACTION

____ The above action(s) are approved. Authority is granted to proceed when funding authority permits.
____ The following must be addressed prior to granting approval of all actions: ______________

_____________________________________________________________________________

_____________________________________________________________________________
Department of Finance

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