QES Management System
Issue Date: 01/07/2014
Constructed verification form
To be lodged by the consultant
City West Water
Email designs@citywestwater.com.au
Service (please select)
Water supply
Recycled water
Sewerage
Pump station
Development details
Location/estate name:
City West Water reference:
Developer:
Consultant:
Contractor:
Consultant nominated representative:
Contractor nominated representative:
Consultant key personnel – Construction Auditor:
Contractor key personnel – Construction Supervisor:
1 Documentation to be submitted (please select):
1.1 evidence that the application to amend the plan of subdivision for the creation of additional easements has been lodged
with council
1.2 relevant As-constructed Verification Form and as-constructed information
1.3 chlorination Completion Certificate in accordance with Clause 1.8.7 of City West Water’s Land Development Manual, if
chlorination of main was required
1.4 water quality testing results for all mains less than 225mm in diameter in accordance with Clause 1.8.7 of City West Water’s
Land Development Manual
1.5 compaction test results in accordance with Clause 1.8.9 of City West Water’s Land Development Manual
1.6 works warranty bond in accordance with Clause 3.1.9 of City West Water’s Land Development Manual
1.7 Verification Attachment Sheet, if any of the items on this form are not applicable.
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QES Management System
Issue Date: 01/07/2014
2 Consultant’s assurance
As the Consultant’s nominated representative responsible for the project management
of the development works detailed in the Development Deed, City West Water reference:
I verify that:
2.1 the as-constructed development works meet:

the scope and requirements of the Development Deed

the design intent and is fit for purpose

relevant WSAA/City West Water specifications and requirements.
2.2 the audit schedule has been satisfactorily undertaken by the construction auditor
2.3 all non-conformances have been satisfactorily resolved and corrective action implemented.
Consultant’s nominated representative
Name:
Company position:
Signature:
Date:
3 Contractor’s assurance
As the Consultant’s nominated representative responsible for the project management
of the development works detailed in the Development Deed, City West Water reference:
I verify that:
3.1 the development works have been constructed in accordance with the requirements of the Development Deed and its referred
documents and standards
3.2 the development works have been satisfactorily supervised by the construction supervisor.
3.3 all non-conformances have been satisfactorily resolved and corrective action implemented.
Contractor’s nominated representative
Name:
Company position:
Signature:
Date:
Important privacy notice
City West Water is a state owned company which provides retail water, sewerage and trade waste services to Melbourne’s central business
district, inner and western suburbs.
By completing this form you are providing personal information to City West Water for the primary purpose of City West Water providing you
with a water or sewerage supply. To read City West Water’s complete privacy statement, please visit citywestwater.com.au
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