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2000 RCSCS Pecification

This document is an application for special inspector certification from the Division of the State Architect of California. It includes information about the applicant such as name, address, work history, and employer. The applicant is applying for certification in masonry and has included their ICC certification number. It outlines the application fees for masonry, shotcrete, and glulam examinations. Upon completion, the applicant's signature verifies the truth and accuracy of the information provided.

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Mikhael Ayoub Mikhael
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33 views1 page

2000 RCSCS Pecification

This document is an application for special inspector certification from the Division of the State Architect of California. It includes information about the applicant such as name, address, work history, and employer. The applicant is applying for certification in masonry and has included their ICC certification number. It outlines the application fees for masonry, shotcrete, and glulam examinations. Upon completion, the applicant's signature verifies the truth and accuracy of the information provided.

Uploaded by

Mikhael Ayoub Mikhael
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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177

DSA SPECIAL INSPECTOR


EXAMINATION APPLICATION
$100.00 MASONRY EXAM APPLICATION FEE (nonrefundable)
$475.00 SHOTCRETE APPLICATION AND EXAM FEE (nonrefundable)
$490.00 GLULAM APPLICATION AND EXAM FEE (nonrefundable)
MAKE CHECK PAYABLE TO: “DSA SPECIAL INSPECTOR EXAM”
Mail application, DSA 650 and the appropriate fee to DSA Inspector Program, 1102 Q Street #5100,
Sacramento, CA 95811
APPLICANT'S INFORMATION:
Last Name First Name M.I.
MIKHAEL MIKHAEL A
Address
2055 S JUNE PL.
City County State ZIP
ANAHEIM ORANGE CA 92802
Day Phone Cell Phone Home Phone
(714) 306-4569 (714) 306-4569
Date of Birth (Must be at least 25 years of age.) Email
06/04/53 MIKHEALM@GMAIL.COM

ICC STRUCTURAL MASONRY SPECIAL CERTIFICATION # (Masonry Applicants): DSA # 5591


ICC REINFORCED CONCRETE SPECIAL CERTIFICATION # (Shotcrete Applicants):

WORK HISTORY: Three years of pertinent experience required for new applicants; not required for renewals.
(See webpage for instructions. Attach additional pages if necessary.)
PROJECT NAME / DESCRIPTION FROM TO DUTIES PERFORMED EMPLOYER
(Cost, # of Stories, Square Footage, DSA or (Mo./Yr.) (Mo./Yr.) (Name and Phone #)
OSHPD File & Application # if applicable)
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:
Name:
Phone:

CURRENT EMPLOYER INFORMATION:


Laboratory Name: MTGL LEA#: 44
Engineering Manager: ISAAC CHUN
Contact#: (714) 632-2999 Email: MTGLINC.COM
I certify under penalty of perjury that all information entered on this application is true and complete. I further understand that any false,
incomplete, or incorrect statements may be cause for voiding this application and any subsequent certification. I authorize the
employers identified on this application to release any information they may have concerning my employment, to the State of California.
I further certify that I will not reveal the contents of the examination to anyone and affirm that I will abide by the rules of the examination.
I understand that upon certification, my name and phone number will be available to the public and posted on the Internet.

________________________________________________________________________ 12/09/17
________________________________________
APPLICANT SIGNATURE DATE SIGNED

DSA 177 (rev 07-14-17) Page 1 of 1


DIVISION OF THE STATE ARCHITECT DEPARTMENT OF GENERAL SERVICES STATE OF CALIFORNIA

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