Report (101) (Yl$7 ..0I7 — 00 J 06
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ti4,7 Bend Office (541)330-9155
i Geotechnical Office (503)6014250
Carlson Testing, Inc. 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 - AREA 1 - LOT 115
CTI JOb#: T1605921.CJ
Address: 17362 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, 2 017 — to perform Special Inspection for:
Permit MST2016-0054'
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. PER BULLETIN DATED 5/15/2 014 FOR THE
Name: TOM _
INSTALLATION OF 5/8" THREADED ROD FOR HDU4
Company: POLYGON NORTHWEST CO HOLDOWNS. RODS HAVE A 5-1/2" EMBEDMENT. HOLDOWNS
2.Inspection was"IBC" Continuous Periodic PLACED ADJACENT TO FRONT DOOR INTO FOUNDATION
WITH 24" SPACING. (2) ANCHORS INSTALLED TODAY.
PROPRIETARY ANCHORS T
YesNoN/A
1.Reviewed previous inspection reports?
2.Reviewed evaluation report? x
Verified following items meet manufacturer's REPORT SUMMARY
published installation instructions.
3.Verified minimum embedment depth of the 1.Work inspected was: ® Completed []In progress
anchors. x
4.Verified installation of the anchors. 2.Completed work inspected was in compliance with
5.Verified anchor diameter. ® Approved plans and specifications 0 Shop drawings
x
6.Verified steel grade. [J RFI ❑ Design change 0 Submittal ❑ N/A
7.Verified hole diameter. x
• Document#(s) BULLETIN Dated: 5/15/2014
8.Verified type of drill bit used. x
9.Verified hole cleaning method. 3.Noncompliance item(s)were noted this date,details on
10.Verified adhesive application. X following page(s). Yes No ® NIA
11.Verified edge distance. 4.Noncompliance item(s)were reinspected this date,details
12.Verified spacing. x on following page(s). Q Yes 0 No EI N/A
13.Verified installation torque. x 0 Conform 0 Remain in progress
Evaluation report number&date: Report(s)findings were discussed and left with
2508 (JULY 2016) 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.
El See additional report page(s). 0 Distribute attachments. Page 1 of ._ 2
Daily Report of Proprietary Anchors For: 06/30/2017
CTI Job#: T1605921.CJ •
Project: POLYGON - NW RIVER TERRACE - AREA 1 - LOT 115
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 fi
without prior authorization from this office.Under all circumstances,the information contained in this report is provided
subject to all terms and conditions of CITs 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.
eI auvul Reviewed By:Project Manager
Project Manager Review Date: 07/10/2017
RM/Ba
CC; POLYGON NORTHWEST CO - CHRIS WALTHER CHRIS.WALTHERSPOLYGONHOMES.COM
CITY OF TIGARD BUILDING DIVISION - WALTER 'CHIP' BARNETT FINA/NCL ONLY
CT ENGINEERING - TODD EATON TEATONSCTENGINEERING.COM
MILBRANDT ARCHITECTS - RICK TOLLESHAUG RBTOMILBRANDTARCH.COM
NORTHWEST EARTHMOVERS INC (NEI) - JEFF DICKSON 3DICKSONSNWEARTHMOVERS.COM
CITY OF TIGARD ENGINEERING DEPT - MIKE WHITE MIKn 5TIGARD-OR.GOV
8430 SW HUNZ1KER ST,TIGARD OR-PO BOX 230997,TIGARD OR 97281
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