Report /3/ "Z.
/� Bend Office (541)330-91.55
/ [sf Ti2! Oj/V Z Geotechnical Office (503)601-825o
Eugene Office (541)345-0289
Carlson Testin Inc. Salem Office (503)589-1252
�9 Tigard Office (503)684-346o
Daily Report of Proprietary Anchors
Project: POWELLRFSIDENCE CTI Job#: T21o4o79
Address: 13191 SW RAPTOR PLTIGARD OR Jurisdiction: TIGARD
CFI representative: Ken Villeneuve was on this site on date: 06/22/2021 to perform
Special Inspection for Permit: MST2o21-00142 PO#: POWELL
SCOPE OF INSPECTION Location of proprietary anchors inspected[to include grid lines,elevations
1. Checked in with superintendent or client representative: (floors)and drawing details]:
Name: JOEL CTI OBSERVED JOEL INSTALL(4)#4 REBAR DOWELS 2
T&B,WITH 4"HORIZONTAL EMB INTO EXISTING NORTH
Company: VORTEX FTG.IN GARAGE FOR NEW CONTINUOUS FTG. &SHEAR
WALL PER PG A2.
2. Inspection was'IBC 0 Continuous QX Periodic
PROPRIETARY ANCHORS
Yes No N/A
1.Reviewed previous inspection reports? X
2.Reviewed evaluation report? X
REPORT SUMMARY
1. Work inspected was: QX Completed 0 In Progress
Verified following items meet manufacturer's published installation 2. Completed work inspected 0 was was not in compliance
materials. with
Yes No N/A
3.Verified minimum embedment depth of the anchors? X 0 Approved plans and specifications Shop Drawings
4.Verified installation of the anchors? X ❑RFI ❑Design Change 0 Submittal N/A
5.Verified anchor diameter? X Doc.No(s): PLANS Dated: 06/06/2021
6.Verified steel grade? X
7.Verified hole diameter? X 3. Noncompliance item(s)were noted this date,details on the following
8.Verified type of drill bit used? X page(s): Yes 0 No N/A
9.Verified hole cleaning method? X" ' 4. Noncompliance item(s)were reinspected this date,details on
1o.Verified adhesive application? X following page(s)Q Yes No QX N/A
r t.Verified edge distance? X 0 Conform 0 Remain in progress
12.Verified spacing? X
13.Verified installation torque? X Report(s)findings were discussed and left with
Evaluation report number and date: JOEL
4057 APRIL 2021
of VORTEX
Name of product being installed:
SIMPSON SET 3G
Batch Number: 1000104182
Expiration Date: 07/28/2022
Based on the code,approval is required from the Building Official before the SPECIAL INSPECTED items noted above can be covered. Carlson
Testing has no authority to direct work of contractors and subcontractors.
See additional report page(s) Distribute Attachment(s) Proprietary Anchors Version I Page I of I