Form Dsa 5 Si PDF Details

The DSA 5 SI form stands as a pivotal document within the sphere of construction, specifically targeting the engagement and approval of Special Inspectors for school projects. Before any work can commence that requires special inspection, this form meticulously outlines the necessity for a Special Inspector to directly contract individually with the School Board, a procedure that mandates detailed agreements and endorsements from various project stakeholders including the Special Inspector, School District/Owner, Design Professional in General Responsible Charge, and, when applicable, the Structural Engineer. The form operates under the directives of the California Code of Regulations, Part 1, Section 4-335(c) 1B, underscoring its legal standing and the procedural rigor required for compliance. Not only does it facilitate the clear specification of project details by the Design Professional, such as project information and the anticipated construction work necessitating special inspection, but it also serves as a record of the Special Inspector’s credentials, experience, and a pledge to adhere to the highest standards of integrity and competency. Further, the form embodies affidavits from the School District/Owner and the Design Professional in General Responsible Charge, each affirming the qualifications of the Special Inspector, their direct responsibility to the project, and the expectation of diligent oversight in accordance with the approved construction documents and applicable codes. This comprehensive documentation is essential for ensuring that all parties involved are suitably informed and agreed upon the roles and responsibilities, aiming to uphold the integrity, safety, and compliance of construction practices in educational environments.

QuestionAnswer
Form NameForm Dsa 5 Si
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesDSA_5 SI dsa 5si form

Form Preview Example

SPECIALINSPECTORQUALIFICATIONANDAPPROVAL

This form must be completed by a Special Inspector who contracts individually and directly with the School Board. It shall be signed and dated by the Special Inspector, School District/Owner, Design Professional in General Responsible Charge, and Structural Engineer (when applicable) prior to submission to DSA. Completed, signed form shall be submitted in advance to the DSA by the Design Professional in General Responsible Charge to ensure DSA approval of special inspector prior to start of work requiring special inspection, per CCR, Part 1, Section 4-335(c) 1B.

Special Inspectors employed by the Laboratory of Record (LOR) do not file this form.

1. PROJECT INFORMATION (To be completed by Design Professional.)

School District/Owner:

 

 

 

 

 

DSA File #:

-

 

 

 

 

 

 

 

 

 

 

Project/School Name:

 

 

 

 

 

DSA App. #:

-

 

 

 

 

 

 

Project Class:

 

Estimated Start Date of construction work requiring special inspection:

 

 

 

 

 

 

 

 

 

Special Inspection Discipline:

Masonry

Shotcrete

Other:

Fabrication:

On-site

Off-site

 

 

 

 

 

 

Type of Inspection:

Periodic

Continuous

 

DSA 5-SI Submittal Date:

 

 

 

 

 

 

 

 

 

 

2. SPECIAL INSPECTOR INFORMATION

Name:

 

Date of Birth:

 

 

 

 

 

Address:

City:

State:

 

ZIP:

 

 

 

 

 

Phone #s:

Email Address:

 

 

 

 

 

 

 

 

Special Inspection Certification

 

 

Expiration

(issuing authority, cert. number):

 

 

Date:

3. SPECIAL INSPECTOR EXPERIENCE RECORD (To be completed by the Special Inspector.)

List at least three previous projects that best qualify you to perform special inspection services for the project described above. For previous projects under DSA jurisdiction, provide the DSA application number.

A. Project Name:

 

 

DSA App. #: (If applicable.)

 

 

 

 

 

 

 

 

Location:

 

 

 

Inspection type:

Periodic

Continuous

 

 

 

 

 

 

 

Discipline:

Masonry

Shotcrete

Other:

 

 

Employer:

Contact Name:

Contact Email Address:

Dates worked on this project

From:To:

Contact Phone #:

B. Project Name:

 

 

DSA App. #: (If applicable.)

 

 

 

 

 

 

 

 

Location:

 

 

 

Inspection type:

Periodic

Continuous

 

 

 

 

 

 

 

Discipline:

Masonry

Shotcrete

Other:

 

 

Employer:

Contact Name:

Contact Email Address:

Dates worked on this project

From:To:

Contact Phone #:

C. Project Name:

 

 

DSA App. #: (If applicable.)

 

 

 

 

 

 

 

 

Location:

 

 

 

Inspection type:

Periodic

Continuous

 

 

 

 

 

 

 

Discipline:

Masonry

Shotcrete

Other:

 

 

Employer:

Contact Name:

Contact Email Address:

Dates worked on this project

From:To:

Contact Phone #:

DSA 5-SI (rev 07-17-13)

 

Page 1 of 2

DIVISION OF THE STATE ARCHITECT

DEPARTMENT OF GENERAL SERVICES

STATE OF CALIFORNIA

DSA 5-SI

Revised 07-17-13

SPECIALINSPECTORQUALIFICATIONANDAPPROVAL

DSA File #:

-

DSA App. #:

-

4.SPECIAL INSPECTOR’S AFFIDAVIT

I hereby certify under penalty of perjury that all information on this form is true, and I agree and understand that any misstatement of material fact contained in this form will be sufficient cause for withdrawal of my DSA approval for this project.

If appointed, I will accept the responsibilities of special inspector and will perform the duties as prescribed by Education Code Sections 17280-17316 (for public schools) or 81130-81147 (for community colleges), or Health and Safety Code Sections 16000-16023 (for essential services buildings).

Signature:

 

Print Name:

 

Date:

Title:

 

 

 

 

 

 

 

 

 

 

 

 

5.SCHOOL DISTRICT/OWNER’S AFFIDAVIT

The special inspector named on this form is being employed individually and directly by the School District/Owner, conditioned upon acceptance by the architect or structural engineer in general responsible charge, and approval by the Division of the State Architect (DSA). This individual is to provide competent, adequate special inspection (as described in Sections 3 and 4 above) during construction of this project. I understand that the special inspector will act under the direction of the project architect or structural engineer in general responsible charge. The special inspector shall be directly responsible to the School District/Owner.

Signature:

 

Print Name:

Date:

 

 

 

 

 

Title:

6.AFFIDAVIT OF DESIGN PROFESSIONAL IN GENERAL RESPONSIBLE CHARGE

I find the Special Inspector named on this form to be suitably qualified and satisfactory to perform special inspection on this project. Per CCR Part 1, Section 4-335(f) 1B, I have personally verified this individual possesses the training, education, experience, and certification necessary to perform the special inspection indicated above. I will monitor the Special Inspector’s activities to assure his/her work is performed in accordance with the requirements of the DSA approved construction documents, and applicable codes and standards. I will verify that the Special Inspector properly documents his/her activities and that reports are distributed as required.

My assessment is based on:

Interview: (Date of interview.) ____________ OR

Prior Professional Relationship.

Signature:

 

Print Name:

 

Date:

 

 

 

 

 

7.AFFIDAVIT OF STRUCTURAL ENGINEER

(Complete when structural work is delegated to Structural Engineer on line 25a of form DSA 1.)

I find the Special Inspector named on this form to be suitably qualified and satisfactory to perform inspection on this project. Per CCR Part 1, Section 4-335(f) 1B, I have personally verified this individual possesses the training, education, experience, and certification necessary to perform the special inspection indicated above. I will monitor the Special Inspector’s activities to assure his/her work is performed in accordance with the requirements of the DSA approved construction documents, and applicable codes and standards. I will also verify that the Special Inspector properly documents all his/her activities and that reports are distributed as required by code.

My assessment is based on:

Interview: (Date of interview.) ____________ OR

Prior Professional Relationship.

Signature:

 

Print Name:

 

Date:

 

 

 

 

 

APPROVAL BY

DIVISION OF

THE STATE

ARCHITECT

Signature of

DSA Field Engineer:

Print Name:

Date:

Submit this form electronically to the DSA Regional Office with construction oversight authority for the project:

DSA OAKLAND

Oakfielddocs@dgs.ca.gov

DSA SACRAMENTO

Sacfielddocs@dgs.ca.gov

DSA LOS ANGELES

LAfielddocs@dgs.ca.gov

DSA SAN DIEGO

SDfielddocs@dgs.ca.gov

DSA 5-SI (rev 07-17-13)

 

Page 2 of 2

DIVISION OF THE STATE ARCHITECT

DEPARTMENT OF GENERAL SERVICES

STATE OF CALIFORNIA

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This PDF doc will require you to provide specific details; to ensure consistency, remember to consider the following suggestions:

1. For starters, once completing the Form Dsa 5 Si, beging with the form section that contains the next blanks:

Step number 1 of filling out Form Dsa 5 Si

2. Just after performing the previous step, head on to the subsequent stage and enter the necessary particulars in all these blanks - Employer, Contact Name, Contact Email Address, B Project Name, Location, Discipline, Masonry, Shotcrete, Other, Employer, Contact Name, Contact Email Address, C Project Name, Location, and Discipline.

Tips to fill in Form Dsa 5 Si step 2

3. The third stage is usually easy - fill out all of the form fields in DSA SI SPECIAL INSPECTOR, SPECIAL INSPECTORS AFFIDAVIT, DSA App, I hereby certify under penalty of, Signature, Title, Print Name, Date, SCHOOL DISTRICTOWNERS AFFIDAVIT, The special inspector named on, Signature, Title, Print Name, and Date to conclude the current step.

Title, SCHOOL DISTRICTOWNERS AFFIDAVIT, and DSA App inside Form Dsa 5 Si

4. This specific subsection comes with these fields to consider: I find the Special Inspector named, My assessment is based on, Interview Date of interview OR, Prior Professional Relationship, Signature, Print Name, Date, AFFIDAVIT OF STRUCTURAL ENGINEER, Complete when structural work is, I find the Special Inspector named, My assessment is based on, Interview Date of interview OR, Prior Professional Relationship, Signature, and Print Name.

Stage # 4 of submitting Form Dsa 5 Si

Be extremely careful when completing Interview Date of interview OR and Signature, since this is the section in which a lot of people make errors.

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