DSA Forms

Many DSA forms are available for download in Adobe Portable Document Format (PDF). The free Adobe Reader software is required to view these forms. You may need to download the most recent version of the Adobe Reader in order to use DSA's more recently revised forms with interactive features. Adobe Reader is available for downloading at: http://www.adobe.com/products/acrobat/readstep2.html.

DSA Forms (Numbered Series)

1–6: DSA's Frequently Used Forms

• DSA-1: Application for Approval of Plans and Specifications (PDF - 229 KB) Revised 4/03/08 || Instructions (PDF 96 KB)
• DSA-1.DEL: Delegation of Responsibility (PDF - 95 KB) Revised 4/25/08
• DSA-1.INC "Definition of Scope of Increments" (PDF - 57 KB) Revised 1/08/07; not fillable
• DSA-2: Application for Evaluation of Existing School Building (PDF - 449 KB) Revised 07/16/07
• DSA-3: Project Submittal Checklist (PDF - 182 KB) Revised 5/02/08 || Instructions (PDF 81 KB)
• DSA-5: Project Inspector Qualification Record (PDF - 522 KB) Revised 8/29/07
• DSA-5A: Assistant Inspector Qualification Record (PDF - 277 KB) Revised 3/22/02
• DSA-6: Verified Report (PDF - 169 KB) Revised 4/11/08 || For Contractors, Inspectors
• DSA-6A/E: Verified Report (PDF - 180 KB) Revised 4/11/08 || For Architects and Engineers

100–191: Includes Project-related, LEA, Gas Shutoff Valve and Inspector Program Forms

• DSA-100-3: Application for Laboratory Evaluation Acceptance (LEA) Program (PDF - 679 KB) Revised 5/01/07
• DSA-102: Contract Information (PDF - 185 KB) Revised 5/31/07
• DSA-103: Structural Tests and Inspections (PDF - 82 KB) Revised 4/01/07; not fillable
• DSA-108: Change in Delegation of Responsibility (PDF - 92 KB) Revised 4/25/08
• DSA-111: Start of Project Report (PDF - 32 KB) Revised 9/10/02; not fillable
• DSA-112: Close of Project Report (PDF - 29 KB) Revised 9/10/02; not fillable
• DSA-121: Checklist for Site Inspection of Relocatable Buildings (PDF 350 KB) Revised 9/10/02
• DSA-122: SB 1469 Inspector's Report (PDF - 148 KB) Revised 06/04/07; not fillable
• DSA-123: SB 1469 Certification of Compliance (PDF - 81 KB) Revised 06/04/07; not fillable
• DSA-145: Record Set Handling Instructions (PDF - 932 KB) Revised 5/01/07 || Instructions
• DSA-180-5.1: Project Inspector's Performance Rating (PDF - 465 KB) Revised 9/13/01; not fillable
• DSA-180-5.1a: Assistant Inspector's Performance Rating (PDF - 315 KB) Revised 9/13/01; not fillable
• DSA-190: Certification of Excess Flow Automatic Gas Shutoff Valve (PDF - 33 KB) Revised 3/31/07; not fillable
• DSA-191: Certification of Seismic Automatic Gas Shutoff Valve (PDF - 33 KB) Revised 3/31/07; not fillable

201–293: Testing Laboratories Forms and Report Templates

• DSA 201: Soil Compaction (PDF - 36 KB)  | (RTF - 102 KB)
• DSA 202: Sieve Analysis (PDF - 46 KB)  | (RTF - 74 KB)
• DSA 203: Tension/Bend (PDF - 36 KB)  | (RTF - 73 KB)
• DSA 204: Compression (PDF - 36 KB)  | (RTF - 89 KB)
• DSA 205: Concrete Masonry Unit (PDF - 79 KB)  | (RTF - 508 KB)
• DSA 206: Anchor Load (PDF - 57 KB)  | (RTF - 65 KB)
• DSA 207: Masonry Core Shear/Compression (PDF - 37 KB)  | (RTF - 76 KB)
• DSA 208: High Strength Bolt (PDF - 51 KB)  | (RTF - 95 KB)
• DSA 209: Fireproofing Density (PDF - 37 KB)  | (RTF - 60 KB)
• DSA 210: Ultrasonic (NDT) (PDF - 39 KB)  | (RTF - 162 KB)
• DSA 250: Special Inspection (PDF - 57 KB)  | (RTF - 45 KB)
• DSA-291: Laboratory Verified Report (PDF - 125 KB) Revised 8/07/06
• DSA-292: Special Inspection Verified Report (PDF - 119 KB) Revised 8/07/06
• DSA-293: Geotechnical Verified Report (PDF - 121 KB) Revised 8/07/06

400–999: Other DSA Forms

• DSA-403: Energy Compliance Checklist (PDF - 208 KB) Revised 5/02/08
• DSA-999: Inspection Verified Report for Projects Exempt from DSA Approval (PDF - 41 KB) Issued 11/16/05; not fillable

DSA Forms (Nonnumbered)

Satellite Office Appointments

• Request for Appointment Form: Bakersfield Satellite Office (PDF - 571 KB) Issued 4/02/07 || Instructions (PDF - 29 KB)
• Request for Appointment Form: Riverside Satellite Office (PDF - 568 KB) Issued 4/30/07 || Instructions (PDF - 28 KB)

SB 1469 Certification

• HCD Relocatable Buildings Reporting Form (PDF - 33 KB) Issued 4/09/02; not fillable