Report ()l ot-3 3. 7
7 K)3 SW s Bend Ofllce ��(541)330-9155
Carlson Testing, Inc. Geotechnical Office (503)601-8250
EugenSalem fiveOffic (541)345-0289
Salem Office (503)589-1252
Tigard Office (503)684-3460
Daily Report of.Aprietary Anchors
Project:] i y5 cj VI t'1 t IR r",-,...-- '° 'tu rrc r--e 14 re 4 J _
Address: S o'er' CTI Job#:T/be)S-'5`2 /
CTI representative e) rime r t S c.h 1
(inspector Name CertNo.) was on site this date l? II S i 7 toperform
Special Inspection for e71Du pmt Ej DFS#(s) Sr `. 1 4 G c 1
jurisdiction T f5"a•v'ra(
In some cases more than one box may be checked for a given item.
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: "?t,, afe1 :cc-n3 f +^Sr'cLe f=vx n' 13GG+1-S
Company: "7�1`t5 ✓� c 4 ie 115 1 2,14, eP � #21 j i 3O
"Pt'€i r-h5'141ere-S'w.)-Pt v.- .Ef I>dr 7
2• tion was"IBC" 1-i I.-4-1
sv i t 1-1''''''' , `s 4 r ' E1
Inspec Continuous 0 Periodic ## y� ''La.".n S 31`: 'jig f C ~)1t e----d-c;
PROPRIETARY ANCHORS
Yes NoNIA
1.Reviewed previous inspection reports?
2.Reviewed evaluation report?
Verified following items meet manufacturer's REPORT'SUIVIMARY
published installation instructions.
I.Work inspected was: p Completed 0 In ro
3.Verified minimum embedment depth of the` p grest
anchors. X 2.Completed work inspected
4.Verified installation of the anchors. m compliance with
5.Verified anchor diameter. El Approved plans and specifications Q Shop drawings
6.Verified steel grade. y 0 RFI 0 Design change 0 Submittal N/
7.Verified hole diameter. K
,f�
o.Verified type of drill bit used. Document#{s) ri 5j»o v,► �`Dated: /S f t/
9.Verified hole cleaning method.
3.Noncompliance item(s)were noted this date,details on
following page(s). El Yes 0 No
10.Verified adhesive application. N/A
11.Verified edge distance.
4.Noncompliance items)were reinspected this date,details
12.Verified
spacing. r on following page(s). Q Yes E No 0 N/A
13.Verified installation torque. y 0 Conform Q Remain in progress
Evaluation report number&date: Report(s)findings were discussed and left with
t s.R 2...s.--e..)9 ', 1 ,
of 711 y se, L,1
Name of product being installed S r rel? 0 r1 ,X' 1E j'2 Z
•
Batch Number Z S s_+t. it-}l?Z ___.__w._--.._._... _...._.....__.._...,......_._._._
Expiration Date c t - _ --- -_4.____
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: "'y ,- 4=--....—_____\._
,
❑ See additional report page(s). Q Distribute attacents
hm . .
-b; Page __of
"'4 PropAnchors Ver.1.2!17!2009. ..,'