LABORATORY LETTERHEAD HERE

DSA FILE #_______________

SPECIAL INSPECTION REPORT

DSA APPL #_______________
DSA / LEA #
Special Inspection Reports must be distributed to the parties listed below within 14 days of the inspection. Reports of non-compliant conditions
must be distributed immediately. Separate reports shall be prepared for each type of special inspection, on a daily basis. Each report shall be
completed and signed by the special inspector conducting the inspection.

Project Name: _____________________________________________________________ Date:

Client Project #: ____________________________________________________________ Time Arrived:
Project Location: ___________________________________________________________ Time Departed:
Contractor: _______________________________ Bldg Permit #: __________________ Travel Time:

Type of Inspection Batch Plant Masonry Fireproofing

Engineered Fill Prestressed Concrete High Strength Bolting _________________
Foundation Shotcrete Welding ________________

DSA Approved Documents:______________________________________________________________

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Work Inspected:
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Use Additional
Sheets if Needed

The Work WAS WAS NOT
INSPECTED IN ACCORDANCE WITH THE REQUIREMENTS
OF THE DSA APPROVED DOCUMENTS
Material Sampling
PERFORMED IN ACCORDANCE WITH
cc: Project Architect
Structural Engineer
Project Inspector
DSA Regional Office
School District
The Work Inspected MET DID NOT MEET
THE REQUIREMENTS OF THE DSA APPROVED DOCUMENTS
WAS WAS NOT N/A
DSA APPROVED DOCUMENTS
Signature of Special Inspector
Print Name / Title
CERTIFICATION #

DSA-250 Template (02/06)