PEMBERI TUGAS PEKERJAAN :

PEMERINTAH PROVINSI JAWA BARAT

"DITULISKAN NAMA INSTANSI PEMBERI KERJA"
"DITULISKAN NAMA PEKERJAAN SESUAI KONTRAK"
" DITULISKAN ALAMAT PEMBERI KERJA"
Lokasi : ....................................................................................
"DITULISKAN ALAMAT WEBSITE PEMBERI NKERJA"
LAMPIRAN BERITA ACARA LAPORAN KEMAJUAN PEKERJAAN
NOMOR SURAT PERJANJIAN (KONTRAK) : .........................................................................
NOMOR ADDENDUM (KONTRAK) : .........................................................................
NOMOR ADDENDUM II (KONTRAK) : .........................................................................
WAKTU PELAKSANAAN : ..............................................HK.

Kontrak Lama KONTRAK CCO REALISASI S/D BULAN LALU REALISASI BULAN INI
NO. URAIAN PEKERJAAN Pekerjaan BOBOT PEKERJAAN BOBOT PEKERJAAN BOBOT
Bobot
(Rp.) (%) (Rp.) (%) (Rp.) (%)

I ..............................................
I.1 .................................
I.2 ...................................
I.3 ...................................

II ..............................................
A.1. ..............................................
A.2. ..............................................
A.3. ..............................................
A.3. ..............................................

0.0000 - - 0.01 0.0000 0.01 0.0000

MENGETAHUI/MENYETUJUI MEGETAHUI
TENAGA BANTUAN TEKNIS
DINAS PERUMAHAN DAN PERMUKIMAN PROVINSI JAWA BARAT

PEJABAT PEMBUAT KOMITMEN PEJABAT PELAKSANA TEKNIS KEGIATAN

KEGIATAN .................................................. KEGIATAN ..................................................
....................................................................... .......................................................................
............................................................
NIP. ...............................................

............................................................ ............................................................ ............................................................

NIP. ............................................... NIP. ............................................... NIP. ...............................................

............................................................
NIP. ...............................................

............................................................
NIP. ...............................................
 KONTRAKTOR PELAKSANA KONSULTAN PENGAWAS

N SESUAI KONTRAK"
"DITULISKAN NAMA "DITULISKAN NAMA
KONTRAKTOR" PENGAWAS"
......................................

MAJUAN PEKERJAAN
MINGGU KE 24
TANGGAL 25 JULI S/D 28 JULI 2016

REALISASI BULAN INI REALISASI S/D BULAN INI SISA

PEKERJAAN BOBOT PEKERJAAN PEKERJAAN Sisa Pekerjaan (Rp) KETERANGAN
(Rp.) (%) (Rp.) (%)

Rp -
Rp -
Rp -

Rp -
Rp -
Rp -
Rp -

- 0.0000 - 0.0000 Rp -

DISETUJUI OLEH DIBUAT OLEH

PELAKSANA KONSULTAN PENGAWAS
.................................. .........................

................................... .................................
DIREKTUR UTAMA KOORDINATOR PENGAWAS
LAMPIRAN BERITA ACARA PEMERIKSAAN PEKERJAAN
Kegiatan : ...........................................................................................
Pekerjaan : .............................................................................................................
Lokasi : ...............................................................................

KONTRAK LAMA KONTRAK BARU (CCO) REALISASI S/D BULAN LALU

NO URAIAN PEKERJAAN HARGA SUB JUMLAH HARGA BOBOT HARGA SATUAN SUB JUMLAH HARGA SUB JUMLAH HARGA
VOLUME SAT VOLUME SAT BOBOT (%) VOLUME
SATUAN (Rp) (Rp) (%) (Rp) (Rp) (Rp)
I .......................................................................
1 Pek. .......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
2 Pek. .......................................................................
- .......................................................................
- .......................................................................
3 Pek. .......................................................................
- .......................................................................
4 Pek. .......................................................................
- .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
.............................
.............................
7 Pek. .......................................................................
.............................
.............................
8 Pek. .......................................................................
.............................
.............................
9 Pek. .......................................................................
.............................
.............................
10 Pek. .......................................................................
.............................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................

Jumlah I 0.00 - 20.4203 0.01 0.0000 0.01

II .......................................................................
1 Pek. .......................................................................
2 Pek. .......................................................................
3 Pek. .......................................................................
4 Pek. .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
7 Pek. .......................................................................
8 Pek. .......................................................................
9 Pek. .......................................................................
10 Pek. .......................................................................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................
18 Pek. .......................................................................
19 Pek. .......................................................................
20 Pek. .......................................................................
21 Pek. .......................................................................
22 Pek. .......................................................................
23 Pek. .......................................................................
24 Pek. .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
25 Pek. .......................................................................
26 Pek. .......................................................................
27 Pek. .......................................................................

Jumlah II 0.00 - 0.0000 - 0.0000 -

TOTAL 0.00 - 20.4203 0.01 - 0.01
LISASI S/D BULAN LALU REALISASI BULAN INI REALISASI S/D BULAN INI SISA PEKERJAAN

SUB JUMLAH HARGA SUB JUMLAH HARGA

BOBOT (%) VOLUME BOBOT (%) VOLUME BOBOT (%) (Rp) BOBOT (%)
(Rp) (Rp)

m2
###
###
###
###
###
###
###

###

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 0.01 0.0000 0.01 - - 0.0000

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 - - - - - 0.0000
12.3770 0.01 - 0.01 - - 0.0000
LAMPIRAN BERITA ACARA PEMERIKSAAN PEKERJAAN
Kegiatan : ...........................................................................................
Pekerjaan : .............................................................................................................
Lokasi : ...............................................................................

KONTRAK LAMA KONTRAK BARU (CCO) REALISASI S/D BULAN LALU

NO URAIAN PEKERJAAN HARGA SUB JUMLAH HARGA BOBOT HARGA SATUAN SUB JUMLAH HARGA SUB JUMLAH HARGA
VOLUME SAT VOLUME SAT BOBOT (%) VOLUME
SATUAN (Rp) (Rp) (%) (Rp) (Rp) (Rp)
III .......................................................................
1 Pek. .......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
2 Pek. .......................................................................
- .......................................................................
- .......................................................................
3 Pek. .......................................................................
- .......................................................................
4 Pek. .......................................................................
- .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
.............................
.............................
7 Pek. .......................................................................
.............................
.............................
8 Pek. .......................................................................
.............................
.............................
9 Pek. .......................................................................
.............................
.............................
10 Pek. .......................................................................
.............................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................

Jumlah I 0.00 - 20.4203 0.01 0.0000 0.01

IV .......................................................................
1 Pek. .......................................................................
2 Pek. .......................................................................
3 Pek. .......................................................................
4 Pek. .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
7 Pek. .......................................................................
8 Pek. .......................................................................
9 Pek. .......................................................................
10 Pek. .......................................................................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................
18 Pek. .......................................................................
19 Pek. .......................................................................
20 Pek. .......................................................................
21 Pek. .......................................................................
22 Pek. .......................................................................
23 Pek. .......................................................................
24 Pek. .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
25 Pek. .......................................................................
26 Pek. .......................................................................
27 Pek. .......................................................................

Jumlah II 0.00 - 0.0000 - 0.0000 -

TOTAL 0.00 - 20.4203 0.01 - 0.01
LISASI S/D BULAN LALU REALISASI BULAN INI REALISASI S/D BULAN INI SISA PEKERJAAN

SUB JUMLAH HARGA SUB JUMLAH HARGA

BOBOT (%) VOLUME BOBOT (%) VOLUME BOBOT (%) (Rp) BOBOT (%)
(Rp) (Rp)

m2
###
###
###
###
###
###
###

###

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 0.01 0.0000 0.01 - - 0.0000

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 - - - - - 0.0000
12.3770 0.01 - 0.01 - - 0.0000
LAMPIRAN BERITA ACARA PEMERIKSAAN PEKERJAAN
Kegiatan : ...........................................................................................
Pekerjaan : .............................................................................................................
Lokasi : ...............................................................................

KONTRAK LAMA KONTRAK BARU (CCO) REALISASI S/D BULAN LALU

NO URAIAN PEKERJAAN HARGA SUB JUMLAH HARGA BOBOT HARGA SATUAN SUB JUMLAH HARGA SUB JUMLAH HARGA
VOLUME SAT VOLUME SAT BOBOT (%) VOLUME
SATUAN (Rp) (Rp) (%) (Rp) (Rp) (Rp)
V .......................................................................
1 Pek. .......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
2 Pek. .......................................................................
- .......................................................................
- .......................................................................
3 Pek. .......................................................................
- .......................................................................
4 Pek. .......................................................................
- .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
.............................
.............................
7 Pek. .......................................................................
.............................
.............................
8 Pek. .......................................................................
.............................
.............................
9 Pek. .......................................................................
.............................
.............................
10 Pek. .......................................................................
.............................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................

Jumlah I 0.00 - 20.4203 0.01 0.0000 0.01

VI .......................................................................
1 Pek. .......................................................................
2 Pek. .......................................................................
3 Pek. .......................................................................
4 Pek. .......................................................................
5 Pek. .......................................................................
6 Pek. .......................................................................
7 Pek. .......................................................................
8 Pek. .......................................................................
9 Pek. .......................................................................
10 Pek. .......................................................................
11 Pek. .......................................................................
12 Pek. .......................................................................
13 Pek. .......................................................................
14 Pek. .......................................................................
15 Pek. .......................................................................
16 Pek. .......................................................................
17 Pek. .......................................................................
18 Pek. .......................................................................
19 Pek. .......................................................................
20 Pek. .......................................................................
21 Pek. .......................................................................
22 Pek. .......................................................................
23 Pek. .......................................................................
24 Pek. .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
- .......................................................................
- .......................................................................
.......................................................................
.......................................................................
- .......................................................................
- .......................................................................
- .......................................................................
25 Pek. .......................................................................
26 Pek. .......................................................................
27 Pek. .......................................................................

Jumlah II 0.00 - 0.0000 - 0.0000 -

TOTAL 0.00 - 20.4203 0.01 - 0.01
LISASI S/D BULAN LALU REALISASI BULAN INI REALISASI S/D BULAN INI SISA PEKERJAAN

SUB JUMLAH HARGA SUB JUMLAH HARGA

BOBOT (%) VOLUME BOBOT (%) VOLUME BOBOT (%) (Rp) BOBOT (%)
(Rp) (Rp)

m2
###
###
###
###
###
###
###

###

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 0.01 0.0000 0.01 - - 0.0000

###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###
###

0.0000 - - - - - 0.0000
12.3770 0.01 - 0.01 - - 0.0000
 PEMBERI TUGAS PEKERJAAN : KONTRAKTOR PELAKSANA
KONSULTAN PENGAWAS:

PEKERJAAN PEMBANGUNAN GEDUNG OLAH RAGA (GOR) 2 DAN 3 ITB JATINANGOR - SUMEDANG (LANJUTAN) PT - LINGKAR PERSADA
PEMERINTAH PROVINSI JAWA BARAT
DINAS PERMUKIMAN DAN PERUMAHAN CV. GRIYA LOKA
Jl. Kawaluyaan Indah No. 4 Telp. (022) 7319782 - 7319735 Fax. 7313675 Bandung
PT. SUBOTA
INTERNATIONAL
Website : Diskimrum.Jabarprov.go.id/e-mail : ppdiskimrum@yahoo.com Lokasi : Jl. Winaya Mukti No.1 Jatinagor - Sumedang CONTRACTOR (KSO)
LAMPIRAN BERITA ACARA PEMERIKSAAN PEKERJAAN
No. Surat Perjanjian (Kontrak) : 602.1/06/SP/33.53/GOR II-III ITB/II/2016
No. Surat Perjanjian addendum : 602.1/ADD.01/SP/33.53/GOR II-III ITB/III/2016 MINGGU KE 16
WAKTU PELAKSANAAN : 150 (SERATUS LIMA PULUH ) HARI KALENDER TANGGAL 30 Mei s/d 05 Juni 2016
KONTRAK BARU Realisasi Bulan Lalu Realisasi Saat ini Realisasi Sampai Saat Ini
Sisa
NO. URAIAN PEKERJAAN Bobot Pekerjaan Bobot Pekerjaan Bobot Pekerjaan Bobot Pekerjaan BobotPekerja Sisa Pekerjaan (Rp) KETERANGAN
an (%)
(%) (Rp.) (%) (Rp.) (%) (Rp.) (%) (Rp.)

I GEDUNG OLAH RAGA 2

I.1 Pekerjaan Arsitektur 0.0000 Rp 2,975,384,711.78 1.4269 Rp 201,700,711.78 0.0000 - 1.4269 Rp 201,700,711.78 -1.4269 Rp 2,773,684,000.00
I.2 Pekerjaan Lain-lain 0.0000 Rp 734,780,598.33 2.4750 #DIV/0! 0.0000 - 2.4750 #DIV/0! -2.4750 #DIV/0!
I.3 Pekerjaan Mekanikal dan Elektrikal #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

II GEDUNG OLAH RAGA 3

A.1. Pekerjaan Arsitektur #REF! #REF! #REF! #REF! #REF! #REF! #REF! Rp 4,244,318,686.09 #REF! #REF!
A.2. Pekerjaan Mekanikal dan Elektrikal #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
A.3. Pekerjaan Mekanikal Elektrikal Site Development #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!
A.3. Pekerjaan Lain-lain #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

#REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF! #REF!

Disetujui Oleh
Kontraktor Pelaksana Dibuat Oleh
PT. LINGKAR PERSADA - Konsultan Pengawas TIM PENERIMA/PEMERIKSA HASIL PEKERJAAN
PT. SUBOTA INTERNATIONAL CONTRACTOR (KSO) CV. GRIYA LOKA

Ariffadillah, ST Ir. Iwan Argo S, IAI Try Budi Hendryanto , ST, MM Asep Dede Sujana, SST Dadang , ST
Direktur Koordinator Pengawas NIP. 19751227 199903 1 003 NIP. 19650506 199803 1 003 NIP. 19670929 200801 1 003

Mengetahui/Menyetujui
Pejabat Pembuat Komitmen
Pembangunan Gedung Olahraga (GOR) II & III ITB-Jatinangor

Boy Iman Nugraha, ST., MT

NIP : 19650826 199403 1 005