( pieczęć placówki)

PROTOKÓŁ
z  okresowej kontroli stanu technicznego i przydatności do użytkowania
 obiektu budowlanego (5 – letni)

Podstawa opracowania: ustawa z dnia 7 lipca 1994 r. Prawo budowlane
 (Dz. U. z 2019 r. poz. 1186), art. 62, ust. 1, pkt 2)

..............................................................................................................................................................................................................................................................................................................
(nazwa i adres placówki)

przeprowadzonej dnia  .............................................  

przez Komisję w składzie:

1.	....................................................................   -  zarządca obiektu oświatowego

2.   ....................................................................   -   upr. bud. Nr   .................................................
                                                                           w  zakresie  .................................................                 
3.   ....................................................................   -    upr. Nr  .......................................................
                                                                       w  zakresie  .................................................                  
4.   ....................................................................   -    ....................................................................

w  obecności:

1.  ........................................................................................
           (inspektor ds. remontów z  Departamentu Edukacji U.M.)
                                                                                                 
2.  ........................................................................................
(Społeczny  Inspektor  Pracy)

stwierdzono co następuje:

1. Ogólna charakterystyka budynku:      .......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................... .................................................................................................................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
..................................................................................................................................................................................................................................
Stan techniczny:

-  instalacji  gazowej:     .................................................................................................................................................................................................................................................................................................................................................................................................................................................................... -  instalacji elektrycznej i odgromowej:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
- instalacji sanitarnej (wod – kan):  
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
- instalacji centralnego ogrzewania:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
- oświetlenie wewnętrzne:  ....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  przewodów spalinowych, kominowych i wentylacji: 
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  innych urządzeń i wyposażenia mogących stanowić  zagrożenie:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

3. .Elementy budynku i budowli – stan techniczny:

-   fundamenty i izolacja obiektu: 
......................................................................................................................................................
.....................................................................................................................................................
......................................................................................................................................................
-   ściany: 
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................-  stropy:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  elewacja:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

-  więźba dachowa – stropodach, pokrycie dachowe i obróbki blacharskie:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
- stolarka okienna i  drzwiowa: ............................................................................................................................................................................................................................................................................................................. ......................................................................................................................................................
-  piwnice:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  ściany i przegrody wewnętrzne:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  posadzki i podłogi:              .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  armatura i osprzęt: 
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  inne elementy wyposażenia:
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  stan kotłowni lub wymiennikowni:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  urządzenia małej architektury  ( boiska, drogi, chodniki, ogrodzenie, śmietniki, plac zabaw )
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  oświetlenie zewnętrzne obiektu i terenu szkolnego:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  zabezpieczenia przed włamaniem, zniszczeniem i kradzieżą:
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................
-  ukrycia i schrony:  
.....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

4.  Wnioski, opinie, uwagi, zalecenia:
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

5.  Zalecane remonty:

    a/   w   bieżącym  roku : 
    ..................................................................................................................................................
............................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................ ....................................................................................................................................................
   
    b/  w  perspektywie lat:
    ..................................................................................................................................................
....................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

6.	 Ostatnia kontrola odbyła się w dniu  ................................ ,  z  ............... (ilości) zaleceń 
    wykonano ……....... , nie wykonano następujących robót:        ………………........................................................................................................................... 
...................................................................................................................................................... 
...................................................................................................................................................... 
...................................................................................................................................................... 

7. Przyczyna niewykonania zaleceń:  
...................................................................................................................................................   .....................................................................................................................................................................................................................................................................................................................................................................................................................................................................

8. Protokół zarejestrowano w książce obiektu budowlanego, tablica nr 5, poz. ............... 

Na tym protokół zakończono i podpisano:

                                                                  Podpisy Komisji: 

1.	..................................................
2.	………………………………..
3.	………………………………..
4.	………………………………..

w  obecności:
 
1.	..................................................
2.	..................................................

Kopię protokołu należy przekazać do Departamentu Edukacji Urzędu Miejskiego w Białymstoku.