NR.:__________________ Incheiat la data de ____________la lucrarea de constructii:________________ _____________________________________________________________________ situate la adresa : _______________________________________________________ cu ocazia receptiei calitative a *___________________________________ _______________________________________________________ 1. Factorii implicati in realizarea lucrarii de constructii: Investitor: ___________________________________________ Proiectant:______________________________________________________ Executant: ______________________________________________________ 2. La baza verificarilor au stat urmatoarele documente: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ __________________________________________________________________ 3. Din verificarile efectuate au rezultat urmatoarele: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 4. Au fost stabilite urmatoarele masuri (concluzii): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5. Mentiuni speciale : _____________________________________________________________________ _____________________________________________________________________ Nota:*) Se completeaza pentru lucrarile ce devin ascunse: cotele si dimensiunile fundatiilor, natura terenului de fundare, aspectul betonului dupa decofrare, pozitionarea golurilor tehnologice si de instalatii, precum si pentru receptia calitativa a lucrarilor pe faze de executie.