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UTILITY RELOCATION COVER SHEET Date: MassDOT Project File No: Project Description: Utility : Design Submittal: Submitted By: Name: Tel. #: Temporary Relocations Included Email: Sketches Attached Estimated Labor Cost: Facility Betterment Estimated Material Cost: Estimated Equipment Cost (if applicable): (If CHECKED, provide brief explanation) Estimated Police Details / Traffic Protection Cost: Estimated SUB CONTRACTOR Cost (if applicable): Estimated Salvage Value (to be subtracted from total): Estimated TOTAL Cost: If NO salvage value included, provide brief explanation:

Aerial Relocations: Total Number of poles necessitating relocation (even if utility is NOT installing the pole): Total amount of wire / cable for relocation (in feet): Brief Explanation of Scope of Work / Other Remarks:

Underground Relocations: Total Number of pipe or conduit for relocation: Total amount of manholes for RELOCATION (Adjustments not included): Brief Explanation of Scope of Relocation Work / Other Remarks:

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