Report (40) CITY OF TIGARD
A Program for Inspection Services and/or Material Testing
Date: to / 14- ,19 ` 1
City of Tigard: Plan Ck. No. 5 Bup No. Sit No. 99 - °c'
Project Title: 764Kn £p. C Address / 2/2V 422 5'9 (,z447 sw bat*%
Architect of Record L /ZS , e,4 . -{ r s Ph. 2Z t — t 12 (
address: / I 2 S Lio — Po2 rua.fp c1:72 e6
Structural Engineer of Record: J -rV1K Ph. s;"Z - ek453
address: 2 -1 , 33 S(- Ete.9 - Potarc.a...q. `t'7zot
Geo- Technical Engineer of Record: Dam I A I,. Q.h Ph. C90 6613
address: 04 SA) d.4 e. ad- Vol,
Tovitio.tl , OICZ O( 2
Provide the following information for the testing agency chosen to provide inspection services and/or testing.
Testing Agency: Ph. Fax.
address //�� �,^�
Geo - Technical Agency:�:CP.0 "' �J1 tlefi1S Ph•(0214 4-1 Fax. &Z
address lt/D4 , (Or f" ( RA . O(Z 5 1 4
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The owner certifies that the above noted Agency has been employed to conduct the
special inspection r observations required herein. I /
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1 6.454-1 _ 1 -7 &mit' tire of Owner hone No „ D
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Print name Company nam
The following is a list of special inspection and/or services required by the 1996 Oregon
Structural Specialty Code and Tigard's Municipal Code 14.06.010 through 14.06.040.
The special inspections and/or testing services required for this project to be provided by the Testing
Agency, Structural Engineer or Geo- Technical Engineer of Record are as follows:
• Special Inspectors for the Testing Agency shall be qualified, to the satisfaction of
the Building Official, for inspections of the particular type of construction or operation.
• Special inspectors shall observe the work assigned herein for conformance with the
approved plans and specifications and, submit copies of all inspection reports and, a
final signed report in accordance with OSSC, Section 1701.3 to the building official.