Report (66) As- 201(0- O(C0(
Bend Office (541) 330-9155
Geotechnical Office (503) 601-8250
Carlson Testing, ugene Office (541) 345-0289
Inc.Inc• Salem Office (503) 589-1252
Tigard Office (503) 684-3460
Daily Report of Proprietary Anchors
Client: POLYGON NORTHWEST CO - CHRIS WALTHER
Project: POLYGON - WEST RIVER TERRACE - AREA 2 - LOT 113 - 13837 CTI Job#: T1605922.D
Address: 13837 SW 174TH LOOP TIGARD OR Jurisdiction: TIGARD
CTI representative B. MULLIGAN WABO SI 01973
was on site this date Jun. 16, 2016 to perform Special Inspection for:
Permit 16-00161
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: MIKE (2) 5/8" THREADED ROD ANCHORS IN HAMMER
Com an POLYGON NORTHWEST CO DRILLED, CLEAN AND DRY HOLES, BLOWN AND BRUSHED,
P y
WITH 59" MINIMUM EMBED.
2. Inspection was "IBC" x Continuous Periodic (1) 10'5" FROM SOUTH EXTERIOR WALL INTERIOR
SHEAR WALL.
PROPRIETARY ANCHORS (1) 5'5" FROM NORTH EXTERIOR WALL IN INTERIOR
YesNoN/A SHEAR WALL.
1. Reviewed previous inspection reports?
--- CONTINUED ON THE BACK ---
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: I x I Completed H In progress
4.Verified installation of the anchors. X 2. Completed work inspected was in compliance with
5. Verified anchor diameter. x Approved plans and specifications I I Shop drawings
6. Verified steel grade. x
7. Verified hole diameter. xI RFI x Design change Submittal N/A
X
8. Verified type of drill bit used. x Document #(s) SEE NARRATIVE Dated:
9. Verified hole cleaning method. X 3. Noncompliance item(s) were noted this date, details on
10. Verified adhesive application. x following page(s). Yes I No N/A
11. Verified edge distance. x
12. Verified spacing. 4. Noncompliance item(s) were reinspected this date, details
x on following page(s). Yes I No x N/A
13. Verified installation torque. x
IConform Remain in progress
Evaluation report number & date:
ESR-2508 (REV 7/2016) Report(s) findings were discussed and left with
MIKE
of POLYGON NORTHWEST CO
Name of product being installed SIMPSON SET XP 22
Batch Number 189Y462Y
Expiration Date 02/20/18
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 2