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<br />BUlL.DING STANDARDS ADMINISTRATI~ )DE APPENDDC <br />(Part 1, Title 24, C.C.R.) <br />Appendis G <br />Sample of Laboratory Verified Report <br />SAMPLE OF LABORATORY VERIFIED REPORT <br />Applit:atian Na <br />Af~daoU <br />Tats is To C~atrtPr, That aA d out tests snd itupection of auterials used in <br />constnsetion of the <br />were made !a accordance with the approved plain sail specificatiats and the rules <br />sail reaalatiom of the tdniaeemard aOMCY) and that all were reported to <br />aid departsnmt <br />AO the tab required by the approved plan: and apectFicatiens were made <br />I eertlfy (or decfase) miler pem&y aF perirsry that I have read the above report <br />and kaow the eoNmb thereof: that all of the above statements are true. <br />NotrnttztN CALffORN1A TFSTWC IdRORATt]RT <br />By <br />Sigruture of duly authorized representative <br />No'tE If all the tats and lsnpec~iorrc required by the approved phuu and <br />spedfkations were tat made by the hdaotory making this affidavit. those which were <br />made shaofd be dther (1} outlined b lieu of the but sentence d the eertifirYte or (2) <br />covered by reference to a letter of imtrvction or check list, from the uchitect or <br />engineer, a copy of which accompanies this afEidavtt <br />35 <br />ZS of ~ 2 <br />