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EXHIBIT 3 <br />DIVISION 4- REFERENCE FORMS <br />4.06 VERIFIED REPORT, FORM G <br />State Leased Buildings and Facilities <br />Verified Report - Form G <br />The Architect having general responsible charge of the work of constructlon on the plans and specifications, is responsible for the submission <br />of this report to the Department of General Services / Real Estate Services Division, Planner (DGS/RESD) prior to the state tenant taking <br />occupancy. <br />RESD Project Info: <br />Agency: Employment Development Department <br />RESD Project # <br />142056 <br />Project Type (Scope of Work): Now Space <br />Date: 4/11/2019 <br />RESD Planner: Carrie Gordon <br />Phone: 916.376.4169 <br />Fax: <br />Facility Info: <br />Building Name <br />Hours of Operation: <br />Address: 801 W. Civic Center Drive <br />Suite <br />City: Santa Ana <br />Zip; 92701 <br />Lessor Contact <br />Phone <br />Fax <br />Contractor: Company Name L 8-'s-e # Phone <br />This reportlncludes all construction work through the dale of: <br />month day year <br />Exterlor Work <br />% Compliant <br />Interior Work <br />% Com p Fla <br />Accessible Main Entrance <br />Parking & Accessible Stalls <br />Doors & Gates <br />Walks & Sidewalks <br />Information / Reception <br />Counter <br />Curb Rams <br />Elevators / Ramps / Lifts <br />Stairways <br />Sanitary Facilities / Slnks / <br />DrInkino Fountains <br />Ramps & Landin s <br />Stairwells / Exits <br />Accessible Main <br />Entrance <br />Conference / Meeting / Assembly <br />Rooms <br />Wayflirding & SI na a <br />I <br />Wayfinding & Si na e <br />Fire Alarms <br />Total Project Percents a of Completion <br />"All Items required to be 100%complete unless Hardship approved by DSA or Mitigation Plan <br />outlined In lease. <br />List work and °/ to be completed (attach additional pages as necossery): <br />I declare under penalty of perjury that I have read the above report and know the contents thereof; that all of the above statements are true and that I know of my <br />own personal knowledge that the worl<during the period covered by the report has been performed and materials used and Installed, and in every material respect <br />are In compliance with the duly approved plans and specli cafions therefore. <br />Architect: <br />Signature <br />Date <br />Name <br />Architect # <br />Company / Finn <br />Phone <br />Address <br />Fax <br />Submit completed forms to location Indicated below: <br />DGS/RESD Real Estate Services Division <br />Attn: Planner 707 Third Street, Suite 5.305 <br />West Sacramento CA 95605 <br />15 <br />(Rev-3/10) <br />80A-657 <br />