Form CGS 1A Application for Assessment of Geologic Hazard Reports - California

Form 1a is a California Department of Conservation form also known as the "Cgs Application Form For Assessment Of Geologic Hazard Reports". The latest edition of the form was released in August 1, 2011 and is available for digital filing.

Download an up-to-date fillable Form 1a in PDF-format down below or look it up on the California Department of Conservation Forms website.

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C
G
S
ALIFORNIA
EOLOGICAL
URVEY
D
C
E P A R T M E N T
O F
O N S E R V A T I O N
APPLICATION
FOR ASSESSMENT OF GEOLOGIC HAZARD REPORTS
CGS Form 1A (08/11)
For CGS use only
CGS project number___________
Date received _______________
In order for CGS to review geologic hazard reports for a proposed school project, as described on Division of the State
Architect (DSA) Interpretation of Regulations IR-4 (see http://www.dgs.ca.gov/dsa/Resources/IRManual.aspx ), the following
material must be submitted to CGS:
this form, which will help CGS and the DSA coordinate reviews;
TWO SIGNED COPIES of the Work Order (attached below), signed by an authorized representative of the District;
a check for $3600 to cover the time and materials needed for CGS review;
Geologic Hazard Reports to be reviewed - ONE copy of each report.
Submit Reports to:
California Geological Survey
School Review Unit
801 K Street, MS 12-32
Sacramento, CA 95814-3531
Name of School:
School District or State Agency:
Mailing Address:
District Superintendent:
Telephone Number:
E-mail Address:
District Director of Facilities:
Telephone Number:
E-mail Address:
Scope of Work:
Applicable Building Code (year):
Community College Project per:
DSA-SS, or
DSA-SS/CC amendments
This project includes a site-specific ground motion analysis in accordance with:
none
ASCE 7
ASCE 41
Project location (Street Address):
City and Zip Code:
County:
APN:
Project Funding Status (Category 1, 2, 3, or 4; per Form DSA-10)
Funding Deadline (if Cat. 4):
Project Tracking Number (PTN):
DSA Application Number (if assigned):
C
G
S
ALIFORNIA
EOLOGICAL
URVEY
D
C
E P A R T M E N T
O F
O N S E R V A T I O N
APPLICATION
FOR ASSESSMENT OF GEOLOGIC HAZARD REPORTS
CGS Form 1A (08/11)
For CGS use only
CGS project number___________
Date received _______________
In order for CGS to review geologic hazard reports for a proposed school project, as described on Division of the State
Architect (DSA) Interpretation of Regulations IR-4 (see http://www.dgs.ca.gov/dsa/Resources/IRManual.aspx ), the following
material must be submitted to CGS:
this form, which will help CGS and the DSA coordinate reviews;
TWO SIGNED COPIES of the Work Order (attached below), signed by an authorized representative of the District;
a check for $3600 to cover the time and materials needed for CGS review;
Geologic Hazard Reports to be reviewed - ONE copy of each report.
Submit Reports to:
California Geological Survey
School Review Unit
801 K Street, MS 12-32
Sacramento, CA 95814-3531
Name of School:
School District or State Agency:
Mailing Address:
District Superintendent:
Telephone Number:
E-mail Address:
District Director of Facilities:
Telephone Number:
E-mail Address:
Scope of Work:
Applicable Building Code (year):
Community College Project per:
DSA-SS, or
DSA-SS/CC amendments
This project includes a site-specific ground motion analysis in accordance with:
none
ASCE 7
ASCE 41
Project location (Street Address):
City and Zip Code:
County:
APN:
Project Funding Status (Category 1, 2, 3, or 4; per Form DSA-10)
Funding Deadline (if Cat. 4):
Project Tracking Number (PTN):
DSA Application Number (if assigned):
APPLICATION FOR ASSESSMENT OF GEOLOGIC HAZARDS REPORTS (p. 2 of 2)
Plans, specifications, and related work were prepared by, and observation of construction will be performed by:
(per Title 24, Part 1, Section 4-316, of the California Code of Regulations)
Architect or Engineer in General Responsible Charge:
Printed Name:
Firm Name:
Address:
Telephone Number:
Fax Number:
California Registration Number:
E-mail Address:
The following individual is authorized to act as Alternate to the Architect or Engineer named above:
Printed Name:
Firm Name:
Address:
Telephone Number:
Fax Number:
California Registration Number:
E-mail Address:
Geologic hazards reports must be prepared by a Certified Engineering Geologist and a Geotechnical Engineer:
(per Title 24, Part 2, Section 1803A, of the California Code of Regulations)
Engineering Geologist Name:
Geotechnical Engineer Name:
Firm Name:
Firm Name:
Address:
Address:
Telephone Number:
Telephone Number:
Fax Number:
Fax Number:
E-mail Address:
E-mail Address:
California Registration Number:
California Registration Number:
For Information regarding review of Geologic Hazard Reports for school projects:
Technical (geology) questions:
Submittal and tracking of reports:
Jennifer Thornburg, PG, CEG, CHG
Margaret Hyland
California Geological Survey
California Geological Survey
801 K Street, MS 12-32, Sacramento, CA 95814-3531
801 K Street, MS 12-32, Sacramento, CA 95814-3531
916.445.5488
916.324.7324
Jennifer.Thornburg@conservation.ca.gov
Margaret.Hyland@conservation.ca.gov
C
G
S
ALIFORNIA
EOLOGICAL
URVEY
D
C
E P A R T M E N T
O F
O N S E R V A T I O N
WO RK O RDER
FOR ASSESSMENT OF GEOLOGIC HAZARD REPORTS
CGS Form 1B (01/11)
The parties to this Work Order are the State of California, Department of Conservation, California
_____________________________________
Geological Survey (CGS) and
(District).
The Parties agree to the following terms and conditions:
1. CGS agrees to conduct an independent assessment of District-provided geologic hazard
report(s) associated with the District’s proposed school construction project to determine
whether the reports are technically adequate.
2. The State of California, Department of General Services, Division of the State Architect (DSA)
will rely upon the CGS technical assessment in reviewing plans for construction of the District’s
proposed construction project and permitting the project. Information regarding CGS
assessment of district geologic hazard reports and the DSA’s instructions to K-12 and
community college districts regarding the CGS assessment can be found in DGS/DSA IR A-4 at
http://www.dgs.ca.gov/dsa/Resources/IRManual.aspx
3. The District shall list the specific reports to be reviewed by CGS in the Application (above). The
District shall provide copies of the reports to CGS when submitting the signed Work Order and
payment, as described below.
4. The District shall provide any additional information determined by CGS to be needed to
complete its assessment.
5. The term of this Work Order shall begin upon full execution of the Work Order by both parties
and shall end in 365 days or 12 months, whichever occurs first. “Full execution” as used herein
means approval by authorized representatives of both Parties and payment to CGS of three
thousand, six hundred dollars ($3600) in consideration of the promise by CGS to perform the
technical assessment. Payment in full shall accompany two copies of this Work Order, each
containing an original signature of a District representative authorized to sign the Work Order.
CGS will return a copy of the Work Order containing an original signature of its authorized
representative upon execution of the Work Order.
6. Failure of the District to submit the necessary documents or the $3,600 payment will result in
termination of this Work Order.
7. No amendment or variation of the terms of this Work Order shall be valid unless made in writing
and signed by both Parties. No oral understanding not incorporated into this Work Order is
binding on either Party.
8. Either Party, in writing, may terminate this Work Order at any time with 30 days written notice;
however, should the District terminate this Work Order after work has been commenced by
CGS, CGS will retain the $3,600 payment for any work completed by CGS prior to the notice of
termination.
WORK ORDER FOR ASSESSMENT OF GEOLOGIC HAZARDS REPORTS (p. 2 of 2)
9. Contact information for each party:
California Geological Survey
District
Name: Jennifer Thornburg, PG, CEG, HG
Name:
Mailing Address: California Geological Survey
Mailing Address:
801 K Street, MS 12-32
Sacramento, CA 95814
Phone Number: 916-324-7324
Phone Number:
10. The Parties agree that the agents and employees of the Parties are independent of the other
and shall not act as officers or employees or agents of the other Party to this Work Order.
11. In addition to the terms contained above, Parties agree to the terms at
http://www.conservation.ca.gov/cgs/rghm/reviews/Documents/Additional_Terms_Conditions.pdf
which are hereby incorporated by reference into this Work Order.
DISTRICT
______________________________
____________
(Signature)
(Date)
Name:
Title:
CALIFORNIA GEOLOGICAL SURVEY
______________________________
____________
(Signature)
(Date)
Name: John G. Parrish, Ph.D.
Title: State Geologist
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