Dsa Form 6 Pi – Fill Out and Use This PDF

This form shall be completed by the Project Inspector, in accordance with California Code of Regulations, Title 24, Part 1, Sections 4-336 or 4-240.

School District/Owner:		DSA File #:	-
Project Name/School:		DSA App. #:	-
Date of Report:	Number of Attached Pages:	DSA 152 Card #(s):
	(If none, enter zero.)
Note that DSA approved construction documents, referred to below, are those portions of
the construction documents, duly approved by the DSA, that contain information related to		List all inspection card numbers for
and affecting the Structural Safety, Fire/Life Safety, and Accessibility portions of the project.		which this verified report applies.

COMPLETE SECTIONS 1, 2, 3 & 4 AND PROVIDE ALL REQUIRED DOCUMENTATION

1.PROJECT INSPECTOR IS EMPLOYED FOR THE FOLLOWING PROJECT SCOPE (Check applicable box.)

Entire scope of the work shown in the DSA approved construction documents

Partial scope of the work shown in the DSA approved construction documents (Briefly describe. Attach additional pages if necessary.):

2.REASON FOR FILING THIS VERIFIED REPORT (Check applicable box.)

Interim Verified Report: List affected form DSA 152 Inspection Card Section #(s):

Final Verified Report: Construction of all work, shown in DSA approved construction documents, is complete.

Building(s) Occupied prior to completion of construction of all work shown in the DSA approved construction documents. List occupied buildings and date of occupancy (Attach additional pages if necessary):

Termination of Project Inspector’s Services prior to completion of construction of all work shown in the DSA approved

construction documents. Provide date of last inspection: _______________ AND check one of the following:

I have previously submitted all semi-monthly reports to the DSA;

I have attached the remaining required semi-monthly report(s) dated:

Construction Work Suspended for more than one month

Provide date of last construction activity: _______________ AND check one of the following:

I have previously submitted all semi-monthly reports to the DSA;

I have attached the remaining required semi-monthly report(s) dated:

DSA Request dated:

3.DEFERRED SUBMITTALS (Check applicable box.)

This project does not require deferred submittals.

All deferred submittals are approved by DSA.

The following deferred submittals are not approved by the DSA (Provide list. Attach additional pages if necessary.):

4. DEVIATIONS AS OF THE DATE OF THIS REPORT (Check applicable box.)

All outstanding deviation related to work shown in the DSA approved construction documents are resolved.

There are unresolved deviations related to work shown in the DSA approved construction documents. They are documented by (Check applicable boxes and provide copies.):

Semi-Monthly Report dated: _______________; Deviation Notices; DSA Field Trip Notes; Other documentation.

I attest that based on my own personal knowledge (as defined in California Code of Regulations, Title 24, Part 1, Sections 4-336 and 4-214) that, except as marked in Sections 3 and 4, as of the date of this report, the work has been performed and materials have been used and installed, in every material respect, in compliance with the DSA approved construction documents. I declare under penalty of perjury that I prepared this report and that all statements are true.

Signature:			Date:
Print Name:			DSA Certification No.:

Submit completed form to the DSA Regional Office with construction oversight authority for the project.

Revised 03/22/13		Page 1 of 1
DIVISION OF THE STATE ARCHITECT	DEPARTMENT OF GENERAL SERVICES	STATE OF CALIFORNIA