Form Dsa 6 C – Fill Out and Use This PDF

6-C

CONTRACTORVERIFIEDREPORT

This form shall be completed by each contractor having a contract with the owner, in accordance with California Code of Regulations, Title 24, Part 1, Sections 4-343 or 4-220. The completed form shall be submitted to the Design Professional in General Responsible Charge, DSA, the project inspector and the school board.

	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 DSA, that contain information related to and		List all inspection card numbers for which
	affecting the Structural Safety, Fire/Life Safety, and Accessibility portions of the project.
			this verified report applies.

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

1.CONTRACTOR INFORMATION (Enter name and check applicable box.) Name of Contractor (Company/Firm) Submitting this Report:

Operating as general contractor responsible for all work shown in the DSA-approved construction documents.

Operating as contractor responsible for part of the work shown in the DSA-approved construction documents. (Describe scope of work in the contract. Attach additional pages, using form DSA 211, if necessary):

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

Final Verified Report: Construction of all work shown in the DSA-approved construction documents that is part of my contract is complete.

Termination of contract prior to completion of all work in the contract (Provide last date of work):

DSA Request dated:

3.DEFERRED SUBMITTALS (Check applicable box.)

This project does not require deferred submittals within the scope of my contract.

All deferred submittals within the scope of my contract are approved by DSA.

The following deferred submittals, within the scope of my contract, are not approved by DSA (Provide list. Attach additional pages, using form DSA 211, if necessary.):

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

There are no outstanding or unresolved deviation notices pertinent to my contract and related to work shown in the DSA- approved construction documents.

There are unresolved deviation notices pertinent to my contract and related to work shown in the DSA-approved construction documents. They are documented by the following form DSA 154 Notice of Deviations (provide list of DSA 154 Notice numbers and attach copies).

There is work pertinent to my contract that is not completed in compliance with the DSA-approved construction documents. (Briefly describe. Attach additional pages, using form DSA 211, if necessary.)

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.

Contractor Signature:			Date:
			Contractor’s
Print Name:			License No.:

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

DSA 6-C (rev 10-28-14)		Page 1 of 1
DIVISION OF THE STATE ARCHITECT	DEPARTMENT OF GENERAL SERVICES	STATE OF CALIFORNIA