Report (
Plan Review # 09/, y- 9L C )3 c.if 9 7 -d CITY OF TIGARD
Date OREGON
Structural Special Inspections
The owner or architect or engineer of record shall complete Parts B & D of this form and then return it to the Building Division for
approval prior to issuance of a building permit. (Please note that a separate soils special inspection form may be required and
additional special inspections may be required for contractor design items.)
Project Address: j/G f--r f w_ (1 e• ,Z, c ' )�. �- . , Project Name: 54
Architect of Record (Firm): Phone No:
Engineer of Record (Firm): Phone No:
The following special inspections and structural observations shall be performed according to the State Building Code and the
City of Tigard's Municipal Code Chapter 14.06.010 - 14.06.040 unless a schedule of inspections is submitted by the Engineer of
Record and approved by the Building Division.
A. ❑ Reinforced Concrete El Prestressed Concrete
❑Structural Steel ,, // ❑Structural Masonry, f'm =
/t/ /jC ❑ Fireproofing
❑ Shop Fabrication Other 1 01 fI .t,V rO'lc ��
B. Indicate the special inspector or approved testing agency to perform the special inspections noted in Part A above,
including addresses and phone numbers. Submit names, qualifications and certifications of the special inspectors
assigned to the project. The special inspector or inspection agency shall submit a final signed report to the Building
Division stating that all items requiring special inspection and testing were fulfilled and reported and, to the best of his/her
knowledge, in conformance with the approved design drawings, specifications, approved change orders and the
applicable workmanship provisions of the U.B.C. (see U.B.C. 3318 for soils special inspection final report requirements).
Items not in conformance, unresolved items or any discrepancies in inspection coverage (i.e., missed inspections,
periodi nspections when continuous was required, etc.) shall be specifically i mized in this report.
l" Z7/e O LE 1w »1 e - ,e -ei ohs M Ze' -
) A ex 32-5- -f it d t9n-1 OJc s 2 0 o ■fliPAWJ:"
C. ❑ Structural Site Observation by Engineer of Record
C . / . The owner hereby agrees to employ the special inspector, approved testing agency and/or engineer for the above -noted
special inspections and/or struc. ral observation.
Signature of Owner / L f �j
Print Name /ed y /7 1 L, 7'0/IJ /� Phone No. /Qa c� 7®(/,Q
Firm Z- 1.E�4411 T /.r■U Date - s 9 /
Structural Plans Examiner signature „eAv,CAS,DOC
13125 SW Hall Blvd., Tigard, OR 97223 (503) 639 -4171 TDD (503) 684 -2772
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