districvowne~s · project inspector . dsa 5 . division of the state architect ~., qualification...
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3-27-0shyDSA 5 project Inspector QuaUficatlon Record lao
4 Inspector Time CommlttmentWorktoad
Specify your lime committmentto this project 0 Full Time (40 hours per week) 0 Part Time (less than 40 hours per week)
Will you be working concurrently on other school projects 0 Yes 0 No I yes list each project below Attach additional sheets if necessary Completion
Project Name amp Location Scope of Construction Work DSA Appllcation status -
Will you be working concurrently on non-school projects or other employment 0 Yes 0 No If yes for each project provide name location scope of construction work your duties and the completion status of the project in the space below Attach additional sheets if necessary
5 Inspectors Affidavit I hereby certify under penally of pe~ury that all answers to the questions on this form are true andmiddot1 agree and understand that any misstatement of malerial fact contained in this form will be sufficient cause for my immediate dismissal If I updertake add~nal work other than stated herein I will secure prior written approval Irom the school districVowner the architect andlor engineergt arid the Div of the State Architecl
II appointed I will accept the responsibilities of inspector and will perform theptlli~s can d me y Sections 1728081130 through 17316181147 of the Education Code or Sections 16000 through 16023 of the Health and S I w- ot BC pt payment or other considerashytion for my services from anyona other than the school districtowner
Signaturemiddot Date 4 -2tt - 0(An original Signature is required
The following affidavits must be signed by an authorized rep res ive of the school districVowner as well as the Design Professional in General Responsible Charge and the Structural Engineer before this apfSlication is submitted to the Division of the State Architect for approval The informashytion provided on this document will be maintained in a public record IIle Original signatures are required
6 School DistrictOwner Affidavit (not required for speclellnspector approval)
_--___--__--__-------___ Is being employed by the schooVowner conditioned upon the acceptance by the architect or regisshytered engineer in general responsible charge and the approval by the DMsion of the State Architect (DSA) to provide competent adequate and conshytinuous inspection during construction of this project I understand that the inspector will act under the direction of the architect or registered engineer In general responsible charge and DSA_ The inspector shall also be responsible to the Owner
Title of school districVowne~s representative completing this affidavit _________________________
Signature ______________ Print Name ____~____---------- Date
7 Affidavit of Design Professional In General Responsible Charge
I lind to be 5uitably qualified and satisfactory to pertorm inspection on this project ecA Va tlt My assessment is based on (check one) 0 Interview (date ____ ____ ) OR ~Prior professional relationship
Signatur Print Name Allmiddot Dale 7 16 Ot
I find ____----RlIioc~hucaLrLld__lIVuaL01e=-_________ to be suitably qualified and satisfactory to perform inspection on this project
OR (prior professional relationship
Monnt Date 72406
The design professional in general responsible charge must submit this completed form 10 the DSA office where the project was filed
Signature Print Name Lonnie
Approval by Signature of FjljldJngineer __~~~==~____~~~~~~-----------
IONf)Division ofthe 00 l l State Archltec frllW~ - ~
Page 20f2
-----------------
CDocuments and SettingsCGreenLocal SetlingsTemporary Internet
JUL S 5 2006 JUL 1 7 2006 Rev 3-27middot03
CALIFORNIA DEPARTMENT OF GENERAL SERVICES ~~ Project Inspector DSA 5 DIVISION OF THE STATE ARCHITECT ~ Qualification Record shy
To be completed by the Inspector Form must be signed by Inspector Owner Design Professional in General Responsible Charge and Slncturnl Enolnoor To bo Ruhmlttnc110 ORA hy rho Dnnia Prnfnnnlnnniin OrlIntnf nUnIHulahl Chnrun n )ltDt 10 dnya pHut Iu otrtll ur wutk
1 Inspector Information
Name Rc JlpR c ~- J
Address jQ BQI ~Ar2 ~ -=r~e A6vlI-ae
CityDoWNS rshy State ~A- Zip 90z4 I Phone 5 ( 81S ) rezs=- Z8 bZ (5~2 ) Q(S-1878
Date of Birth _~ middotZ 7 _(Q
Type of DSA approval requested 0 Project Inspector
Project Inspector Class ____ DSA Certificate __
2 Project Information
School DistricVOwner Needles Unified School District
Scope of Work
DSA File No 36-H5
DSA Application No 04-106610
Willlhe inspector be in the ~ emplo~ of the school district 0 Yes ~ No If no indicate inspectors employer
0 Relocatable Building In-planl (RBIP) )rOther AW5 -cWT ____ __ Expiration Date ____ -1r tJiJ 3tJ1
Project Name (School) Needles Hi h School
Estimated Cost $
3 Experience Recordmiddot Ust the three previous projects that best Qualify you to perform inspection services for the project entered in item 2 For previous schOOl projects provide the DSA applica1ion number in the middotProject Name field
Project Name Chapman College Rim School
Construction Cosi S-28O000=0-0_____________
Check one 0 New Construction 0 Alteration 0 Relocalable Bldgs
Structural systems 01 new construction or structural alterations
oWood Shear Wall DConcretampMasonry Shear Wall o Steel Frame
PrOject Name Target Store Redondo Beach
Construction Cost $_1_=0000=0=0_____________
Check one 0 New Construction 0 Alteralion 0 Relocatable Bldgs bull
Structural systems 01 new construction or structural alterations
oWOOd Shear Wall 0ConcreteMasonry Shear Wall 0Steel Frame
Project Name Kasier Hospital
San Diego
Conslruclion Cost S-=2500~O~O0~___________
l bullbull tDuh ~a UNow LoulIDJULl1 ljAHolaUu Uht~CllcJlNa Ul~b
middotStructural systems of new construction or structural alterations
0 Wood Shear Wall 0 ConcreteMasonry Shear Wall 0 Steel Frame
Job Title OProjectlnspeclor o Fielo Superintendent
oConstruction Trade _____________
00ther Welding Inspection
Dates employed FROM _4_1o_5_____ TO 605 ____
Employ8r_Tu~rner~______________________________
Employers Phone ( 949 l 263-2828
Job Title 0 Project Inspector o Field Superintendent
OConstrUCior Trade _______________
(lether Concrete amp Staellnspection
Dates employed FROM _1--105_____ TO 405
Employer Whiting and Turner
Employers Phone ( 310 838-3134
Job Title OProjecllnspector o Field Superintendent
DConstruction Trade _____________
DOlher ______________
Ulb lIIluyU I-I1UM =J1obull_____ TO IfU4
Employer Twining Laboratories
Employer~ Phone ( 858 l 974middot3756
Page 1 of 2
_-----------------C=-ID=--=ocu=mcenct=--sand SettingslCGreenlLocal SettingslT-=empcoraryLlntecrnect_________________
3-27-03DSA 5 PrOject Inspector Qualilication Record
4 Inspectors Time CommlttrnentJWorkload
Specify your time committment to this project 0 Full Time (40 hours per week) 0 Part Time (less Ihan 40 hours per week)
Will you be working concurrently on olner school projects 0 Yes 0 No If yes lisl each project below Anach additional sheets il necessary Completion
Project Name amp Location Scope of Construction Work DSA Applicalion status -
Will you be working concurrently on nonmiddotschool projects or other employment 0 Yes 0 No If yes tor each project provide name location scope 01 construction work your duties and the compleli on status of the project in the space below Anach additional sheets if necessary
5 Inspectors Affidavit I hereby certify under penalty of pe~ury that all answers to the questions on this form are true al1d-f agree and understand that any misstatement of malerial fact contained in this form will be sufficient cause for my immediate dismissal II I uj)dertake add~nal work other than stated herein I will secure prior writlen approval from the school districtowner the architect andror enginee~arid the Div trot the Slate Architect
It appointed I will accept the responsibilities of inspector and will perform theooties can d u me y Sections 726061130 through 17316161147 of the Education Code or Sections 16000 through 16023 olthe Hljalth and S bull I~ ot ac pt payment or otherconsiderashytion for my services from anyone other than the school districtowner
An original signature is required Signature Date 4 -2 I - C The lollowing alfidavits must be signed by an authorized repres tlve of the school dislricUowner as well as the Design Prolessional in General Responsible Charge and the Structural Engineer before this apPlication is submitted 10 the Division of the Slate Archilect for approval The informashytion provided on this document will be maintained in a pubic record lile Original signatures artJ required
6 School DlstrlcVOwners Affidavit (not required for special Inspector approval)
_____--_____-_--___ is being employed by the schoolowner conditioned upon the acceptance by the architect or regis tered engineer in general responsible charge and the approval by the Division of the State Architect (DSA) to provide competent adequate and conshytinuous Inspection during construction of this project I understand that the Inspector will act under the direction of the architect or registered engineer in general responsible charge and DSA The inspector shall also be responsible to the Owner
TiUe of school districVowners representative completing this affidavit _________________________
Signature __________ Prinl Name Date
7 Affidavit 1)1 Design Professional In General ResponsIble Charge
I find to be suitably qualified and satisfactory to pertorm inspection on this project focAJ Va tlt My assessment is based on (checK one) 0 Interview (date ____ ~ Prior professional relationship
Date 7 ~ 0(Signatur Print Name M
I find ____-IR)IiJcLhLCaurJd-JVlJaallue~_________ to be suitably qualified and satisfactory to perlorm inspection on this project
OR j(prior professional relationship
Signature _~~~~~~==--____ Print Name _~LO O O 1 bull ________ Date 72 4 0 6 e__--Mou-OLJt
The design professional in general responsible charge must submit this completed form to the DSA office where the project was med 1 IUII
Approval sect1 I c bull by Signature of F~I~i~ngineer ______________________________-__
Division of the 0030 ~ State Archltec ~rt NIamp~ 1 L Date
1middot middot3 Page 2 of 201 I~ bullJ J
-----------------
CDocuments and SettingsCGreenLocal SetlingsTemporary Internet
JUL S 5 2006 JUL 1 7 2006 Rev 3-27middot03
CALIFORNIA DEPARTMENT OF GENERAL SERVICES ~~ Project Inspector DSA 5 DIVISION OF THE STATE ARCHITECT ~ Qualification Record shy
To be completed by the Inspector Form must be signed by Inspector Owner Design Professional in General Responsible Charge and Slncturnl Enolnoor To bo Ruhmlttnc110 ORA hy rho Dnnia Prnfnnnlnnniin OrlIntnf nUnIHulahl Chnrun n )ltDt 10 dnya pHut Iu otrtll ur wutk
1 Inspector Information
Name Rc JlpR c ~- J
Address jQ BQI ~Ar2 ~ -=r~e A6vlI-ae
CityDoWNS rshy State ~A- Zip 90z4 I Phone 5 ( 81S ) rezs=- Z8 bZ (5~2 ) Q(S-1878
Date of Birth _~ middotZ 7 _(Q
Type of DSA approval requested 0 Project Inspector
Project Inspector Class ____ DSA Certificate __
2 Project Information
School DistricVOwner Needles Unified School District
Scope of Work
DSA File No 36-H5
DSA Application No 04-106610
Willlhe inspector be in the ~ emplo~ of the school district 0 Yes ~ No If no indicate inspectors employer
0 Relocatable Building In-planl (RBIP) )rOther AW5 -cWT ____ __ Expiration Date ____ -1r tJiJ 3tJ1
Project Name (School) Needles Hi h School
Estimated Cost $
3 Experience Recordmiddot Ust the three previous projects that best Qualify you to perform inspection services for the project entered in item 2 For previous schOOl projects provide the DSA applica1ion number in the middotProject Name field
Project Name Chapman College Rim School
Construction Cosi S-28O000=0-0_____________
Check one 0 New Construction 0 Alteration 0 Relocalable Bldgs
Structural systems 01 new construction or structural alterations
oWood Shear Wall DConcretampMasonry Shear Wall o Steel Frame
PrOject Name Target Store Redondo Beach
Construction Cost $_1_=0000=0=0_____________
Check one 0 New Construction 0 Alteralion 0 Relocatable Bldgs bull
Structural systems 01 new construction or structural alterations
oWOOd Shear Wall 0ConcreteMasonry Shear Wall 0Steel Frame
Project Name Kasier Hospital
San Diego
Conslruclion Cost S-=2500~O~O0~___________
l bullbull tDuh ~a UNow LoulIDJULl1 ljAHolaUu Uht~CllcJlNa Ul~b
middotStructural systems of new construction or structural alterations
0 Wood Shear Wall 0 ConcreteMasonry Shear Wall 0 Steel Frame
Job Title OProjectlnspeclor o Fielo Superintendent
oConstruction Trade _____________
00ther Welding Inspection
Dates employed FROM _4_1o_5_____ TO 605 ____
Employ8r_Tu~rner~______________________________
Employers Phone ( 949 l 263-2828
Job Title 0 Project Inspector o Field Superintendent
OConstrUCior Trade _______________
(lether Concrete amp Staellnspection
Dates employed FROM _1--105_____ TO 405
Employer Whiting and Turner
Employers Phone ( 310 838-3134
Job Title OProjecllnspector o Field Superintendent
DConstruction Trade _____________
DOlher ______________
Ulb lIIluyU I-I1UM =J1obull_____ TO IfU4
Employer Twining Laboratories
Employer~ Phone ( 858 l 974middot3756
Page 1 of 2
_-----------------C=-ID=--=ocu=mcenct=--sand SettingslCGreenlLocal SettingslT-=empcoraryLlntecrnect_________________
3-27-03DSA 5 PrOject Inspector Qualilication Record
4 Inspectors Time CommlttrnentJWorkload
Specify your time committment to this project 0 Full Time (40 hours per week) 0 Part Time (less Ihan 40 hours per week)
Will you be working concurrently on olner school projects 0 Yes 0 No If yes lisl each project below Anach additional sheets il necessary Completion
Project Name amp Location Scope of Construction Work DSA Applicalion status -
Will you be working concurrently on nonmiddotschool projects or other employment 0 Yes 0 No If yes tor each project provide name location scope 01 construction work your duties and the compleli on status of the project in the space below Anach additional sheets if necessary
5 Inspectors Affidavit I hereby certify under penalty of pe~ury that all answers to the questions on this form are true al1d-f agree and understand that any misstatement of malerial fact contained in this form will be sufficient cause for my immediate dismissal II I uj)dertake add~nal work other than stated herein I will secure prior writlen approval from the school districtowner the architect andror enginee~arid the Div trot the Slate Architect
It appointed I will accept the responsibilities of inspector and will perform theooties can d u me y Sections 726061130 through 17316161147 of the Education Code or Sections 16000 through 16023 olthe Hljalth and S bull I~ ot ac pt payment or otherconsiderashytion for my services from anyone other than the school districtowner
An original signature is required Signature Date 4 -2 I - C The lollowing alfidavits must be signed by an authorized repres tlve of the school dislricUowner as well as the Design Prolessional in General Responsible Charge and the Structural Engineer before this apPlication is submitted 10 the Division of the Slate Archilect for approval The informashytion provided on this document will be maintained in a pubic record lile Original signatures artJ required
6 School DlstrlcVOwners Affidavit (not required for special Inspector approval)
_____--_____-_--___ is being employed by the schoolowner conditioned upon the acceptance by the architect or regis tered engineer in general responsible charge and the approval by the Division of the State Architect (DSA) to provide competent adequate and conshytinuous Inspection during construction of this project I understand that the Inspector will act under the direction of the architect or registered engineer in general responsible charge and DSA The inspector shall also be responsible to the Owner
TiUe of school districVowners representative completing this affidavit _________________________
Signature __________ Prinl Name Date
7 Affidavit 1)1 Design Professional In General ResponsIble Charge
I find to be suitably qualified and satisfactory to pertorm inspection on this project focAJ Va tlt My assessment is based on (checK one) 0 Interview (date ____ ~ Prior professional relationship
Date 7 ~ 0(Signatur Print Name M
I find ____-IR)IiJcLhLCaurJd-JVlJaallue~_________ to be suitably qualified and satisfactory to perlorm inspection on this project
OR j(prior professional relationship
Signature _~~~~~~==--____ Print Name _~LO O O 1 bull ________ Date 72 4 0 6 e__--Mou-OLJt
The design professional in general responsible charge must submit this completed form to the DSA office where the project was med 1 IUII
Approval sect1 I c bull by Signature of F~I~i~ngineer ______________________________-__
Division of the 0030 ~ State Archltec ~rt NIamp~ 1 L Date
1middot middot3 Page 2 of 201 I~ bullJ J
_-----------------C=-ID=--=ocu=mcenct=--sand SettingslCGreenlLocal SettingslT-=empcoraryLlntecrnect_________________
3-27-03DSA 5 PrOject Inspector Qualilication Record
4 Inspectors Time CommlttrnentJWorkload
Specify your time committment to this project 0 Full Time (40 hours per week) 0 Part Time (less Ihan 40 hours per week)
Will you be working concurrently on olner school projects 0 Yes 0 No If yes lisl each project below Anach additional sheets il necessary Completion
Project Name amp Location Scope of Construction Work DSA Applicalion status -
Will you be working concurrently on nonmiddotschool projects or other employment 0 Yes 0 No If yes tor each project provide name location scope 01 construction work your duties and the compleli on status of the project in the space below Anach additional sheets if necessary
5 Inspectors Affidavit I hereby certify under penalty of pe~ury that all answers to the questions on this form are true al1d-f agree and understand that any misstatement of malerial fact contained in this form will be sufficient cause for my immediate dismissal II I uj)dertake add~nal work other than stated herein I will secure prior writlen approval from the school districtowner the architect andror enginee~arid the Div trot the Slate Architect
It appointed I will accept the responsibilities of inspector and will perform theooties can d u me y Sections 726061130 through 17316161147 of the Education Code or Sections 16000 through 16023 olthe Hljalth and S bull I~ ot ac pt payment or otherconsiderashytion for my services from anyone other than the school districtowner
An original signature is required Signature Date 4 -2 I - C The lollowing alfidavits must be signed by an authorized repres tlve of the school dislricUowner as well as the Design Prolessional in General Responsible Charge and the Structural Engineer before this apPlication is submitted 10 the Division of the Slate Archilect for approval The informashytion provided on this document will be maintained in a pubic record lile Original signatures artJ required
6 School DlstrlcVOwners Affidavit (not required for special Inspector approval)
_____--_____-_--___ is being employed by the schoolowner conditioned upon the acceptance by the architect or regis tered engineer in general responsible charge and the approval by the Division of the State Architect (DSA) to provide competent adequate and conshytinuous Inspection during construction of this project I understand that the Inspector will act under the direction of the architect or registered engineer in general responsible charge and DSA The inspector shall also be responsible to the Owner
TiUe of school districVowners representative completing this affidavit _________________________
Signature __________ Prinl Name Date
7 Affidavit 1)1 Design Professional In General ResponsIble Charge
I find to be suitably qualified and satisfactory to pertorm inspection on this project focAJ Va tlt My assessment is based on (checK one) 0 Interview (date ____ ~ Prior professional relationship
Date 7 ~ 0(Signatur Print Name M
I find ____-IR)IiJcLhLCaurJd-JVlJaallue~_________ to be suitably qualified and satisfactory to perlorm inspection on this project
OR j(prior professional relationship
Signature _~~~~~~==--____ Print Name _~LO O O 1 bull ________ Date 72 4 0 6 e__--Mou-OLJt
The design professional in general responsible charge must submit this completed form to the DSA office where the project was med 1 IUII
Approval sect1 I c bull by Signature of F~I~i~ngineer ______________________________-__
Division of the 0030 ~ State Archltec ~rt NIamp~ 1 L Date
1middot middot3 Page 2 of 201 I~ bullJ J