Report Bend Office (541) 330-9155
Geotechnical Office (503) 601-8250
Carlson Testing, Ince Eugene Office (541) 345-0289
Salem Office (503) 589-1252
Tigard Office (503) 684-3460
Daily Report of Proprietary Anchors
Client: POLYGON NORTHWEST CO - CHRIS WALTHER
Project: POLYGON - NW RIVER TERRACE - AREI? 1 - LOT 121 CTI Job#: T1605921.CL
Address: 17494 SW SHADOW TRAIL ST TIGARD OR Jurisdiction: TIGARD
CTI representative R. MONTGOMERY OBOA 1119/WABO SI 02145,WABO 3592
was on site this date Jun. 30, 2017 to perform Special Inspection for:
Permit MST2016-00530
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: TOM PER BULLETIN DATED 5/15/2014 FOR THE
Com an POLYGON NORTHWEST CO INSTALLATION OF 5/8" THREADED ROD FOR HDU4
p y HOLDOWNS. RODS HAVE A 5-1/2" EMBEDMENT. HOLDOWNS
2. Inspection was "IBC" x Continuous Periodic PLACED ADJACENT TO FRONT DOOR INTO FOUNDATION
WITH 24" SPACING. (2) ANCHORS INSTALLED TODAY.
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 1 ,
anchors. x l'.--Work inspected was: x Completed In progress
4.Verified installation of the anchors. x 2. Completed work inspected was in compliance with
5. Verified anchor diameter. X I xi Approved plans and specifications Shop drawings
6. Verified steel grade. x
RFI Design change Submittal N/A
7. Verified hole diameter.
8. Verified type of drill bit used. x Document #(s) BULLETIN Dated: 5/15/2014
9. Verified hole cleaning method. X 3. Noncompliance item(s) were noted this date, details on
10. Verified adhesive application. x following page(s). I I Yes No x N/A
11. Verified edge distance. x
12. Verified spacing. X 4. Noncompliance item(s) were reinspected this date, details
13. Verified installation torque. x on following page(s). Yes No x N/A
I Conform Remain in progress
Evaluation report number & date:
2508 (JULY 2016) Report(s) findings were discussed and left with
TOM
of POLYGON NORTHWEST CO
Name of product being installed SIMPSON SET XP
Batch Number 095Z146Z 155Z378Z
Expiration Date 4/2018 5/2018
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
Daily Report of Proprietary Anchors For: 06/30/2017
CTI Job#: T1605921.CL
Project: POLYGON - NW RIVER TERRACE - AREA 1 - LOT 121
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 ofCTI'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:Project Manager
Project Manager Review Date:07/10/2017
RM/BB
CC: POLYGON NORTHWEST CO - CHRIS WALTHER CHRIS.WALTHER@POLYGONHOMES.COM
CITY OF TIGARD BUILDING DIVISION - WALTER 'CHIP' BARNETT FINA/NCL ONLY
CT ENGINEERING - TODD EATON TEATON@CTENGINEERING.COM
MILBRANDT ARCHITECTS - RICK TOLLESHAUG RBT@MILBRANDTARCH.COM
NORTHWEST EARTHMOVERS INC (NEI) - JEFF DICKSON JDICKSON@NWEARTHMOVERS.COM
CITY OF TIGARD ENGINEERING DEPT - MIKE WHITE MIKEW@TIGARD-OR.GOV
8430 SW HUNZIKER ST,TIGARD OR-PO BOX 230997,TIGARD OR 97281
Page 2 of 2