HomeMy WebLinkAboutSpecial Inspection Field Test & Inspection Report 1996-1-1
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have filliShed, ICkno\Vledge all undel1landing of lha informalion by signing balow, and ~tum Ihl. fOITll to lba City.
......, ''"MOT CAN "ISSU,O, ". _. -'. ................ ".1..... -.r," ...." ..,r_" ,"".... ..... _,1'0, .......d ....."
10 lhe Cily for revie" and approvallhls fonn completed on bolh rhe /Tonr Ind back.
Tho Ow....d o....r c..,~... ..,. .P'.... "'" ok. ............ __ ....... .,.'... . ""," "_ ..... Tw""
I. Conlrulol' is responsible for proper nOlirleallon for !he InspeClion or Testing of floms Ibled,
2. Tnllll!: laboralol')' sJlllltalco apPropriato umplOl and trllrulpolt!hem 10 their IaboralOI)' for proper evaluallon or lesting.
. Copies of IIr laboralOI)' rCf'Orts and IRSpetlions uelo ba senl 10 Ihe City by rhe Testing Agency.
3. SpctiallnspccUon ACClley is 10 submii nanes and q~lirJCalions of on.sile Specialln.p<cton to the City for approval.
4. Spe.lallaspeerol' 511111 provide inspeclioll roJlOrll to !he building omcial of alllnspeclion Icdvities.
S. Contro.'or is responsible 10 rev;'IVlIlC City approved plans for addilionaJ inspection or lestlng "'q<liremenlslh.at llIay be naled.
"""', , ""TI"", TE 0' OCcuP'NC, WILL" IS'U"" Tho -, '""'''' '..." ...."...."... "''''''' 0_', ....... ... .. ..~...... .
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ACKNOWLEDGMENTS
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O....cr Name (Prinled) f1.
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Engineer cw Architecl Finn (Prinled)
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Building PelTllir Ii
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Projecl1ille
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Projecl ^ddtess v
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City of Springfield
Community Services Division
225 Fifill Street
SprIngfield. OR 97477
Telephone: (541) 726.3759
FIX: (541) 726-3689
Special Inspection And Testing
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Clen. Contractor Finn Nama (Prwed)
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Telling Laboratol)' Nama (Printed)
Special JOSpoclion Agency NlImo (Printed)
101/1n1 LIboralory Rop Siglllluro
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Building Official Namo (Prinled)
Building Official Sl8narure
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Cil)' of SpringflC:Jd
Communily Services ~ivision
225 Finh Street
SprIngfield, OR 97477
relep/lone: (541) 726.3759
FIX: (541) 726-3689
Specilll Inspection And Testing
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Building Penni! Ii
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Dale
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P'~jecl' Tille
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Projecl Address
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have fiuished, oclnowledge au unde~taudin8 ofllla infOlTnalion by signing belol\', and rerum Ihls fonn 10 Iha Cil)'.
"PO.. , "'MIT CAN" "'.'D, n. -....... ......,.,... ~ .. ".i..".. ~",... "".. ",._" A"'""" .~. ''''~'' "" ~d .....,
to I'" Cily for review and .pprovallhls fonn completed on boIh rhe fronr and back.
Th, 0... Ud "'~, c.,,_, .... ......., "'".... -''''.. "" _... .....,.... ..,"'." '",", ,._ ,"""""""C.
I. Con',..elol' is responsible for proper notiflcalion for the hl.1peelion or Tesling of flams listed.
2. Testlllg laboralol')' shall lake apPropriale IImpl.. and transport them 10 their Iaborato/)' for proper evaluation or leSling.
. Copies ofllllaboralOIY reports and Inspections are 10 be senl 10 Ihe Cil)' by rhe Tesllng Agency.
3. Speciallnspectloll Aeelley is 10 submil n.n.. and qu.,if..alions o( on-site Specie/Inspectors to Ihe City (or approval,
4. Speel.llaspecIOl'Slulll provide inspecliOlI raJlOf1s 10 the building official of all Inspection lecivilies.
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''''JR' A CORn"CA,., 0' OCcrJ'ANCY WILL RE ISSUeo, Th, """"."",. .....', "" ~... . "" """'. 0_,. ....... .. ,. ,,~""''''C .
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Engineer Oll,,~hilccc Signature
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_T<fl/lnal.abor.l..y Rep~i2.1II..1urO
ACKNOWLEDGMENTS
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O.....er NIllle CPr; led) ~~1."
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Engineer or Archilecl Film (Prulledf
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Testing Leboralo/)' Name (Printed)
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Special lospection Agoncy Nama (Prinled)
Building Official Nama CPrinled)
Building Omelal Slgna[Ure
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