Form DSA-6 – Fill Out and Use This PDF

FORM

DSA-6

Rev 8/10

VERIFIED REPORT

File this report at completion of project, when services in connection with the project are terminated, when work stops for more than one month, or when any building of the project is occupied. See instructions on page 2. Refer also to California Code of Regulations, Title 24, Part 1, Sections 4-214 (for essential services buildings) and 4-336 (for schools).

1.		FINAL - All Work completed (entire DSA approved scope is 100% complete)			3.	DSA File No.
2.	Check all	Work not completed (describe in box 10 below)		Terminating			DSA Application No.
applicable				Work Stopped
boxes:
		Occupied Building(s) ______________________________________________				-
4.	School District/Owner:		5. Project Name (School):

6.Scope of Entire Project

10.Describe all non-compliant work and/or work to be completed (______additional pages attached):

11. Total No. of change orders received:		Total No. of DSA approved change orders received:

12.I know of my own personal knowledge that the work described on this report has, in every material respect, been performed in compliance with the DSA approved documents. I declare under penalty of perjury that I prepared this report and that all statements are true.

Signature: ____________________________________ Print Name: _______________________________________ Date: _______________

Serving as:	Project Inspector				Contractor				Other: ________________________________
Business Address:___________________________________________________________________________________________________
City: __________________________________________________________________________ State:											Zip _________________

13. Contractor must also complete the following:

I am an authorized official of

working in the capacity of

with personal knowledge of the work of construction. I have been authorized by said firm or corporation to sign this report.

Submit completed form to the DSA Regional Office where this project was constructed:

DSA Oakland Region	DSA Sacramento Region	DSA Los Angeles Region	DSA San Diego Region
1515 Clay Street, Suite 1201	1102 Q Street, Suite 5200	700 N. Alameda Street, Suite 5-500	10920 Via Frontera Rd., Suite 300
Oakland, CA 94612	Sacramento, CA 95811	Los Angeles, CA 90012	San Diego, CA 92127

Form DSA-6 (rev 08-31-10)

CALIFORNIA DEPARTMENT OF GENERAL SERVICE

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Instructions for Form DSA-6

The Inspector and Contractor(s) each complete and send separate forms to DSA.

The Inspector DOES NOT complete Section 13

1.Inspectors - Check “Final - Work 100% complete” ONLY when all work in the entire scope of the DSA application is completed in accordance with DSA approved documents. Construction contractors - Check this box only if all work in your contract has been completed in accordance with DSA approved documents. Both - If addenda, change orders or other documents are pending approval or if corrective work is required CHECK BOX 2 INSTEAD.

2.Check “Work not completed (describe in box 10 below)” when work is not 100% complete. Also, check one or more of the other three boxes to indicate the status of the project:

 Check “Occupied Building(s)		” when building(s) involved in the project are occupied or reoccupied
List the name(s) of the building(s).

Check “Terminating” when your services have ended on the project for any reason.

Check “Work Stopped” when construction work has stopped for more than one month.

3.Provide DSA file and application number (file number is shown above the approval stamp on the first sheet of the drawings or the signature page of the specifications; application number appears on all approval stamps).

4.Enter the name of the School District or owner; provide an explanation in Section 10 for projects on school grounds that are not owned by the school district.

5.Project name must include the name of the school(s) where construction work is performed.

6.List scope of entire project as shown on DSA approved documents even if this report only pertains to a portion of that scope. See http://www.applications.dgs.ca.gov/dsa/eTrackerWeb/ConstructionProject.htm to verify project scope. See http://www.dsa.dgs.ca.gov/PlanRev/scope.htm for standard nomenclature for describing the scope of the project.

7.Inspectors may enter “all” or list all contracts covered by this report; contractors enter the number assigned to your contract by the architect.

8.Inspectors enter total final project cost including all change orders. Contractors enter total final cost for your contract. Include the cost of all change orders and construction management contracts.

9.Inspectors enter total percentage of completion for the entire project scope; contractors enter total for your contract.

DO NOT ENTER 100% UNLESS ALL ADDENDA, CHANGE ORDERS, ETC HAVE BEEN APPROVED BY DSA AND THE ENTIRE SCOPE OF WORK, INCLUDING ALL TESTING AND INSPECTION, HAS BEEN COMPLETED AND VERIFIED PER ALL DSA APPROVED DOCUMENTS.

10.Include a description of all non-compliant and/or incomplete work. For “phased" projects or for contracts that cover only a part of the project, describe the scope of the applicable “phase” or contract. When certification of a “portion” of the scope is requested, indicate percentage of completion of the “portion” of scope constructed. If additional pages are needed, check the box and indicate the number of pages attached.

11.Enter the total number of change orders received and the total number of DSA approved change orders received. All change orders must be approved by DSA before the work may be considered 100% complete.

12.For the inspector, “all work” includes all construction as well as verification that all tests and special inspections have been performed. For the contractor “all work” means the work included in the scope of your contract. When construction is performed by school district employees or volunteers, a responsible school district employee must act as the “contractor” for the project and sign the form.

For the inspector “personal knowledge” means:

The actual personal knowledge which is obtained from the inspector’s personal continuous inspection of the work in all stages of its progress. For work performed away from the site, the project inspector may obtain personal knowledge from the reporting of testing or special inspection of materials and workmanship for compliance with approved plans, specifications and applicable standards. The exercise of reasonable diligence to obtain the facts is required.

For the contractor “personal knowledge” means:

The personal knowledge gained from constructing the building. The exercise of reasonable diligence to obtain the facts is required.

13.This section is for the contractor only; the inspector does not fill out Section 13. The contractor reports the name of the firm they represent on the first line and their official capacity (general superintendent, owner, etc) on the second line. When construction is performed by school district employees or volunteers, a responsible school district employee must act as the “contractor” for the project, sign the form in Section 12, and complete Section 13.

Form DSA-6 (rev 08-31-10)

CALIFORNIA DEPARTMENT OF GENERAL SERVICE

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