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DIVISION 4—REFERENCE FORMS <br />State Leased Buildings and Facilities <br />Verifled Report - Form G <br />The Architect having general responsible charge of the work of construction on the plans and specifcations, 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 In <br />Agency: Employment DeIvelopmerif Department <br />RESD Project # <br />142056 <br />Project Type (Scope of Work): New Space <br />Date: 4/11/2019 <br />RESD Planner: Carrie Gordon <br />.Phone: 916.375.4169 <br />Fax: <br />Facility Info: <br />Suildln Name - <br />„,.�.. <br />Hours of Operation: <br />Address: 01 W. Civic Center Drive <br />Suite <br />Cityt Santa <br />Zip: 92701 <br />Lessor Contact Phone <br />Fax <br />This, report includes all consiruction work through the date of: month_ day year <br />Exterior Wark <br />%-Corn liant <br />Interior Work <br />% Compliant <br />Accessible Main Entrance <br />Perkin ' Atccessible Stalls <br />Doors & Gates <br />Walks & Sidewalks <br />Information / Reception <br />Counter <br />Curb Rani s <br />Elevators / Ram s /Lifts <br />Stairways <br />Sanitary Facilities /Sinks / <br />Drinkn Fountains <br />Ram s & LandingsaPlan <br />Stairwells / Exits <br />Accessible Mainrence <br />Entrance <br />/ Meeting CAssembly <br />Rooms, <br />Wa ntlin 8 Si na "eWa <br />Indin & Si na' e <br />Fire Alarms <br />t Percents e of Com letiom <br />'All Items required to be i00% complete unless Hardship approved by DSA <br />outlined In lease <br />List work and % to be completed (attach additional pages as necessary): <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 work -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 specifications therefore. <br />Architect: <br />Signature <br />Name <br />Architect # <br />Company / Firm <br />Phone <br />Address <br />Fax <br />Submit completed forms to location indicated below: <br />DGSIRESD Real Estate Services Division <br />Attn: Planner 707 Third Street, Suite 5-305 <br />West Sacramento CA 95605 <br />,� 5 (Rev-3/19) <br />