Cod Document : A3 - 05

Unitatea: _________________ Lucrarea:

_________________

Obiectul: _________________
__________________

PROCES VERBAL DE PREDARE-PRIMIRE A AMPLASAMENTULUI SI A

BORNELOR DE REPER LA OBIECTUL
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Incheiat astazi _______________________________

1. Delimitarea terenului conf. plan de situatie nr. ___________ avind coordonatele (axele)

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__________________________________ Plansa nr. __________ Proiect nr.

_________________ cu reperele de identificare a terenului si trasare a lucrarilor (bornele,

constructiile etc.)

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____________________________________________________ Indicativul bornei de

referinta _______________________ cota ______________________ Cota absoluta =

borna 1 borna 2 borna 3 borna 4

Coordonata x x x x
_____________ _____________ _____________ _____________

(Axa) y y y y
_____________ _____________ _____________ _____________

z z z z
_____________ _____________ _____________ _____________

2. Constructii - instalatii existente pe amplasament sau in subsol.

Denumirea Descrierea situatiei Termen de Executant
eliberare
1 2 3 4

1
3. ALTE MENTIUNI

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PREDAT: PRIMIT:
Numele si Functia Semnatura Numele si Functia Semnatura
prenumele prenumele
- BENEFICIAR: ANTREPRENOR

- PROIECTANT: CONSULTANT: