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Report Main Office alem Office Bend Office P.O. Box 23814 4060 Hudson Ave., NE P.O. Box 7918 Carlson Testing Inc. Tigard, (5 03) 684 -3 68 93461 0 Phone ( 503) 5 9 89 - 125 Bend. 2 Phone ( 541) 3 97708 5 hone (503) 684-3460 503)5125o541)3-915 9 Phone (503) 684 -0954 Fax (503) 589 -1309 Fax (541) 330-9163 Daily Report of Proprietary Anchors Client: SJM CONSTRUCTION - STEWART MARSH Project: POTTHOFF RESIDENCE - ADDITION CTI Job #: T0807538. Address: 11710 SW ANN STREET TIGARD OR Jurisdiction: TIGARD CTl representative J. KING OBOA 416 was on site this date Jul. 11, 2008 to perform Special Inspection for: Permit MST2008 -00080 DFS #(s) PO Number: SCOPE OF INSPECTION Location of proprietary anchors inspected [to include grid 1. Checked in with superintendent or client representative. lines, elevations (floors) and drawing details]: Name: DAN #4 REBAR INTO EXISTING CONCRETE FOR FOOTING Company: SJM 2. Inspection was "IBC" © Continuous ❑ Periodic 3. Work performed: © In the field ❑ At precast shop 4. If shop inspection do they have fabrication and QC procedures? ❑ Yes ❑ No © N/A PROPRIETARY ANCHORS REPORT SUMMARY Yes No N/A 1. Reviewed previous inspection reports? x 1. Work inspected was: ® Completed ❑ In progress 2. Reviewed evaluation report? x 3. Verified manufacturer's anchor use conforms 2. Completed work inspected was in compliance with X A roved plans and specifications Shop acceptance criteria in report summary. © PP P P ❑ P drawings Verified following items meet manufacturer's ❑ RFI ❑ Design change ❑ Submittal ❑ N/A published installation instructions. 4. Verified minimum embedment depth of the Document #(s) Dated: anchors. x 3. Noncompliance item(s) were noted this date, details on 5.Verified installation of the anchors. x following page(s). ❑ Yes ❑ No ❑ N/A 6. Verified anchor diameter. x 7. Verified steel grade. x 4. Noncompliance item(s) were reinspected this date, details 8. Verified hole diameter. on following page(s). ❑ Yes ❑ No ® N/A X 9. Verified type of drill bit used. x ❑ Conform ❑ Remain in progress 10. Verified cleanliness of hole and anchor. x 11. Verified adhesive application. x Report(s) findings were discussed and left with DAN Evaluation report number 1772 o f SJM Name of product being installed S IMPSON SET Batch Number 107196PP Expiration Date 10/31/09 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. ❑ See additional report page(s). ❑ Distribute attachments. Page 1 of 1 Daily Report of Proprietary Ancho. For: 07/11/2008 CTI Job #: T0807538. Project: POTTHOFF RESIDENCE - ADDITION 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. If there are any further questions regarding this matter, please do not hesitate to contact this office. Respectfully submitted, CARLSON TESTING, INC. Reviewed By: Keith Gauvin Review Date: 07/21/2008 JK /JAP SJM CONSTRUCTION - STEWART MARSH TO: CITY OF TIGARD BUILDING DIVISION HAYDEN CONSULTING ENGINEERS TATHWELL DESIGN ASSOCIATES Main Office ,alem Office Bend Office s� y� Testing, Inc. Box 23814 4060 Hudson Ave., NE P.O. Box 7918 Carlson Inc. Tigard, Oregon Salem, Oregon 9 1 Bend, 97708 Phone (503) 03) 684 -346-346 0 Phone (50503) ) 5 589 -1252 Phone (541) 541) 330-9155 5 Fax (503) 684 -0954 Fax (503) 589 -1309 Fax (541) 330 -9163 Daily Report of Proprietary Anchors Client: SJM CONSTRUCTION - STEWART MARSH Project: POTTHOFF RESIDENCE - ADDITION CTI Job #: T0807538. Address: 11710 SW ANN STREET TIGARD OR Jurisdiction: TIGARD CTI representative C MANGINO OBOA 807 was on site this date Auq. 27, 2008 to perform Special Inspection for: Permit MST2008 -00080 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. PHD5 HOLDDOWNS WEST OF REAR DECK ENTRANCE PER Name: DAN DETAIL A3 /CD3.3. Company: CJM CONST 2. Inspection was "IBC" © Continuous 0 Periodic SIMPSON SET EPDXY IS APPROVED FOR THIS PROJECT. PROPRIETARY ANCHORS Yes NoN /A 1. Reviewed previous inspection reports? X 2. Reviewed evaluation report? X Verified following items meet manufacturer's ' . REPORT SUMMARY published installation instructions. 3. Verified minimum embedment depth of the 1. Work inspected was: © Completed 0 In progress anchors. X 4.Verified installation of the anchors. 2. Completed work inspected was in compliance with © Approved plans and specifications ❑ Shop drawings 5. Verified anchor diameter. X 6. Verified steel grade. RFI Design change Submittal ❑ N/A 7. Verified hole diameter. X Document #(s) Dated: 8. Verified type of drill bit used. X 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 No N/A 11. Verified edge distance. X 4. Noncompliance item(s) were reinspected this date, details 12. Verified spacing. X on following page(s). fl Yes ❑ No ® N/A 13. Verified installation torque. X 0 Conform ❑ Remain in progress Evaluation report number & date: Report(s) findings were discussed and left with ESR -1772 DAN 2008 of SJM CONST Name of product being installed SIMPSON SET 22 Batch Number 167196PP 181378RR Expiration Date 10 -09 05 -10 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. ❑ See additional report page(s). 0 Distribute attachments. Page 1 of 1 • Daily Report of Proprietary Ancho.. For: 08/27/2008 CTI .lob #: T0807538. Project: POTTHOFF RESIDENCE - ADDITION 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. If there are any further questions regarding this matter, please do not hesitate to contact this office. Respectfully submitted, CARLSON TESTING, INC. Reviewed By: Keith Gauvin Review Date: 09/11/2008 CM /JWA SJM CONSTRUCTION - STEWART MARSH TO: CITY OF TIGARD BUILDING DIVISION HAYDEN CONSULTING ENGINEERS TATHWELL DESIGN ASSOCIATES