Report (3) Bend Office (541)330-9155
Geotechnical Office (503)601-8250
Eugene Office (541)345-0289
Carlson Testing� Inc. Salem office (503)589-1252 Tigard Office (503)684-346o84-3460
Daily Report of Proprietary Anchors
Project: POLYGON AT ROSHAK RIDGE-LOT 9 CTI Job#: Ti8o4799•AH
Address: 14309 SW 168TH AVE TIGARD OR Jurisdiction: TIGARD
CTI representative: Darell Martini was on this site on date: o4/0i/2o2o to perform
Special Inspection for Permit: MST2o19-00076 PO#:
SCOPE OF INSPECTION Location of concrete placement[to include grid lines,elevations(floors)
1. Checked in with superintendent or client representative: and drawing details]:
1.REVIEWED THE FOLLOWING DOCUMENTS;
Name: KALEB A.A7,NO REVISION,2-18-19
Company: POLYGON B.FOR STAMPED LETTER DATED 5-1 5-r 4 DETAILING
HDU2 HOLD DOWN CRITERIA.
2.MONTTORED POLYGON INSTALL(`t EA)5/8"X 2 4"
2. Inspection was'IBC ❑X Continuous ❑Periodic A3o7 THREADED ROD,6"EmBEDmENT FORHDU2
HOLDDOWN IN GARAGE FOUN)AION NO DISCREPANCIES
PROPRIETARY ANCHORS WERENOTED.
Yes No N/A
1.Reviewed previous inspection reports? X REPORT SUMMARY
2.Reviewed evaluation report? X
1. Work inspected : ❑X Completed ❑In Progress
Verified following items meet manufacturer's published installation 2. Crlxpletedwork inspected ❑X was ❑was not in compliance
materials. with
Yes No N/A
3.Verified minimum embedment depth of the anchors? X ❑X Approved plans and specifications Shop❑ Drawings
4.Verified installation of the anchors? X ❑RFI ❑Design Change ❑Submittal ❑N/A
5.Verified anchor diameter? X Doc.No(s): SEE TEXT Dated: 04/01/2020
6.Verified steel grade? X
7.Verified hole diameter? X 3• Noncompliance item(s)were noted this date,details on the following
8.Verified type of drill bit used? X page(s): Yes ❑X No ❑N/A
9.Verified hole cleaning method? X 4. Noncompliance item(s)were reinspected this date,details on
10.Verified adhesive application? X following page(s)❑Yes ❑X No ❑N/A
11.Verified edge distance? X ❑Conform ❑Remain in progress
12.Verified spacing?
13.Verified installation torque? X Report(s)findings were discussed and left with
KALEB
Evaluation report number and date:
ESR 2508,1-2020
of POLYGON
Name of product being installed:
SIMPSON SET XP
Batch Number: 1000034232
Expiration Date: 03/27/2021
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 and subcontractors.
❑See xklitional report pays) Distribute Attactumnt(s) Pro}niamy Anchors Version 1 Page 1 of 1