Report (2) Zo2i- 7t7
Bend Office (541) 330-9155
Geotechnical Office (503) 601-8250
Carlson Testing, ffice (541) 345-0289
Inc. Eugene O
Salem Office (503) 589-1252
Tigard Office (503) 684-3460
Daily Report of Proprietary Anchors
Client: POLYGON NORTHWEST CO - ANGELA GRAJEWSKI
Project: POLYGON AT ROSHAK RIDGE LOT 155 CTI Job#: T1804799.CC
Address: 16714 SW SUNSHINE COAST 1-6di*RD----- Jurisdiction: TIGARD
CTI representative K. JORDISON WABO SI 01967/ACI 01133121/ICC 8008055
was on site this date Jul. 16, 2021 to perform Special Inspection for:
Permit MST2021-00070
DFS #(s) PO Number:
SCOPE OF INSPECTION Location of proprietary anchors inspected [to include grid
lines, elevations (floors) and drawing details]:
1. Checked in with superintendent or client representative.
Name: ROB OBSERVED INSTALLATION OF FOUR #4 REBAR VERTICAL
Company: TAYLOR MORRISON DOWELS AT GARAGE WING WALLS PER BULLLETIN CT
-102 (6/21/21)
2. Inspection was "IBC" ❑ Continuous x Periodic
PROPRIETARY ANCHORS
YesNoN/A
1. Reviewed previous inspection reports? X
2. Reviewed evaluation report? X
Verified following items meet manufacturer's
published installation instructions. REPORT SUMMARY
3. Verified minimum embedment depth of the
anchors. X 1. Work inspected was: 2 Completed ❑ In progress
4.Verified installation of the anchors. X 2. Completed work inspected was in compliance with
5. Verified anchor diameter. X L_X] Approved plans and specifications n Shop drawings
6. Verified steel grade. X n RFI ❑ Design change ❑ Submittal n N/A
7. Verified hole diameter. X
8. Verified type of drill bit used. X Document #(s) CT ENGINEERING
O Dated: 06-21-2021
9. Verified hole cleaning method. X 3. Noncompliance item(s) were noted this date, details on
10. Verified adhesive application. X following page(s). n Yes ri No 7 N/A
11. Verified edge distance.
12. Verified spacing. 4. Noncompliance item(s) were reinspected this date, details
X on following page(s). ❑ Yes ❑ No E N/A
13. Verified installation torque. X
Conform n Remain in progress
Evaluation report number & date:
ESR 4057 EXPIRES 4/22 Report(s) findings were discussed and left with
ROB
of TAYLOR MORRISON
Name of product being installed SIMPSON SET 3-G
Batch Number 1000094415
Expiration Date 2022-06-09
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 or subcontractors.
CSee additional report page(s). Distribute attachments. Page 1 of 2
Daily Report of Proprietary Anchors For: 07/16/2021
CTI Job #: T1804799.CC
Project: POLYGON AT ROSHAK RIDGE - LOT 155
Notes:
In some cases more than one box may be checked for a given item on the front page.
Our reports pertain to the material tested/inspected only.Information contained herein is not to be reproduced,except in full,
without prior authorization from this office.Under all circumstances,the information contained in this report is provided
subject to all terms and conditions of CTI's General Conditions in effect at the time this report is prepared.No party other
than those to whom CTI has distributed this report shall be entitled to use or rely upon the information contained in this
document.
If there are any further questions regarding this matter,please do not hesitate to contact this office.
Respectfully submitted,
CARLSON TESTING,INC.
Keith Gauvin Reviewed By: Steven W Leach
Project Manager Review Date:07/16/2021
KEJ/KEJ
CC:• POLYGON NORTHWEST CO - ANGELA GRAJEWSKI TAYLORMORRISON_AP@ONLINECAPTURECENTER.COM
CITY OF TIGARD BUILDING DIVISION - WALTER 'CHIP' BARNETT FINAL/NCL ONLY
X
8430 SW HUNZIKER ST,TIGARD OR-PO BOX 230997,TIGARD OR 97281
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