Report (38)M57 -;W17- 000q3
7 3,r,2 Bend Office (MI) no -9155
Geotechnical Offlee (503) 601-8250
Eugene Office (541)345-0289
Carlson Testing, Inc. Salem offlee0599-1252
TIPM 0mce �5503)) 684-3460
Daily Report of Proprietary Anchors
n LA.,
Pnjict)
Address: 5 *Ie® q 44-4 r CTI Job #--r-1k6575Z I
cri representative gr�d -was onsite this date bil.T/1-7 toperform
(kmpector Narne & Cert. No.)
Special Inspection for -set-, 'R t 4 r. C' jurisdiction T I'S e,- go -e-1
Permit 0 DFS #(S)
In some cam more than 6ne box may be chocked for a given item
SCOPE OF INSPECTION Location of proprietary anchors inspected [to include grid
lines, elevations (floors) and drawing details]:
1. Chocked in with superintendent or client representative. Pcicl ri I r-cr-,Aq
Name 4 ie 74:5 rZ-7 I I go
Company- r.
2. inspection was continuous Periodic
rcd LA-- I' TF -01 S: A
Q Le w b
PROPRIETARY ANCHORS
Y.esNoWA,
TY -1
1. pr"iow t;w�;rp—wv
1 2. Reviewed evaluation report?
REPORT SUAM"Yo,
Verified following items meet mm&icturees
published installation instructions.
1. Work inspected was: ffl Completed 0 In
3. V ed emit NX oftbe
anchors.
Y
4.Vedfied installation of the anchors.
S. Verified anchor diameter.
6. Verified steel grade.
7. Verilighole diameter.
)c
S. Verified type of -drillbit used.
9. Verified hole ;Im--ftia ;Zo—dL
10. Verified adhesive application.
)r
71. —Verified edge distance.
C
12. Verified spacing.
13. Verified installationtorque.
.2. Complded.work.inspecte;d was
in compliance with
R1 Approved plans and specifications
[] Shop drawings
E] RFI [] Design chanZ..,0&*=iW N/tk
Document #(s) w Dated:- 5-Aej
I-rf f1l.-
3. Noncompliance itern(s) were noted dim date, details on
following page(s). 0 Yes 0 No N/A
4. Noncompliance item(s) were reinspected this date, de-taffs,
on following page(s). F1 Yes F1 No N/A
[] Conform 0 Remain in progress
Evaluation report mm'ba & date- Report(s) findings were discussed andieft with
F -S jz z -7 r3l 'Yl
Nam ofproduct being installed $-;M?,t'0') WXP"27-
of Tee 1 40 fA
Batch Number 7,q;:IL IL16Z
Expiration Date
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.
Inspector Signature: !!�54 Mi.— ic.-�.�
Fj See additional report page(s). Distribute attac Page —2rof