HomeMy WebLinkAboutCBPR-5-11-10865 Statement of Special Inspections.tif SICC 2009 - Appendix A Blank Forms
Page 1 of 3 CATAWBA COUNTY, NORTH CAROLINA
SPECIAL INSPECTIONS PROGRAM
Statement of Special Inspections
TPI Permit #1: TPI Permit #2: TPI Permit #3
(TPI Permit Numbers to be furnished by CCBSD)
9 w U L)LAUT co'`, 4A-1 10 � 110'? c t tl WS `bra .
PROJECT: ���_�JT NCBC Edition: 2 -"
Address: _ _
SG CJs 0,KR& - D LTA4010 2P Occupancy: S ij5-,6 JI
a A,7r g1°IOT / AJ G ( 6 Construction Type: S
Building Owner: PI /2,-' [
Name Company
Owner's Address: ��- (� g� dtk F6lLD C7 Of7 �'Lr�� A.D. G �O
Architect of Record: An uc- b 11 t A/je ;Z% PAC4-1
' / « V / I Name & License Th � - Company
Structural Engineer of Record: taaA' (y h y 14 L, ,� U16L,(,p.
Name & License Company
Geotechnical Engineer of Record: f - L oZ - 3e G s Ca�9c.tNl4S I.( _p
N
In , ame & License Company
Special Inspections Engineer of Record 1 : A y, 4 -Be j�z, U 2zw3o PGS 64�C.Lm/ia LL p
Name & License Company
Special Inspections Engineer of Record 2:
Name & License Company
Special Inspections Engineer of Record 3:
h� Name & License Company
General Contractor: Vp_.y[p LtJ&siyV)' 444 57 9 -Z- - TWI/dt CmysTh . (:�O I
T
Name & License Company
This Statement of Special Inspections is submitted as a condition for permit issuance in accordance with the North Carolina Statewide
Building Code.
The Special Inspections Engineer of Record shall keep records of specified special inspections and testing and shall furnish copies of
inspection and testing reports to the Catawba County Building Services Division and to the appropriate registered design professionals
of record. Discrepancies from the approved plans and specifications and code violations observed during the conduct of special
inspections services shall be brought to the immediate attention of the contractor for correction, to the attention of the Catawba County
Building Services Division, and to the appropriate registered design professionals of record. A final report of special inspections
documenting completion of specified special inspections and correction of any discrepancies and observed code violations noted in the
inspection and testing reports shall be submitted to the Catawba County Building Services Division prior to the request for final building
inspection and building inspection approval by County staff.
Prepared by Registered Design Professional in Responsible Charge:
AXtX 1 P. �G�Qn 9L-0
(Type or print) Name Signature & Date
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Building Owner's Authorization: p7 �I
Signature & Date
Building Official's Acceptance:
Catawba County Building Services Signature & Date
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1
SICC 2009 - Appendix A Blank Forms
,l
Page g STATEMENT OF SPECIAL INSPECTIONS Date:
PROJECT:
0 FO11'n tc2L T���YVhF�I" rUl� ►t �1 P >, Ip t� e �... y
ACTIVITY /SYSTEMS Y/N AGENT ` Continuous or Periodic Inspection ref. below
Steel Construction, Fabrication & NC Building Code 1704.2, 1704.3, 1707,
Seismic Resistance 1708.4 & SICC Chapter 6
Concrete Construction, Fabrication & NC Building Code 1704.2, 1704.4, 1708.3
Seismic Resistance Y SICC Chapter 7 & 8
Masonry Construction, Fabrication &
NC Building Code 1704.2, 1704.5, 1708.1 &
Seismic Resistance' SICC Chapter 9
Wood Construction,. Fabrication & NC Building Code 1704.2, 1704.6, 1707.3
Seismic Resistance & SICC Chapter 10
Soils NC Buildin Code 1704.7 & SICC Ch. 11 .
Pile Foundations &Fabricators NC Building Code 1704.2, 1704.8, 1808,
1809, 1810, 1811 & SICC Section 1104.2
Pier Foundations NC Building Code 1704.9,1808,1812&
SICC Section 1104.2
Earth Retention Systems NC Building Code 1806.2 & SICC Ch. 12
Sprayed Fire Resistance Materials fJ NC Building Code 1704.10 & SICC'Ch. 13
Mastic & Intumescent fire- resistant coatings Tj NC Building Code 1704.11 & SICC Ch. 13
EIFS NC Building Code 1704.12 &.SICC'Ch. 14
Smoke Control N NC Building Code 1704.14 & SICC Ch. 15
Seismic Resistance Architectural, NC Building Code 1705.3 pars 4.2, 4.3, 4.4,
Components 4.5, &1707.7 & SICC Ch.16
Seismic Resistance Mechanical NC Building Code 1705.3 para 2- 5, 1707.8,
Components k 1707.9, 1707.10, & 1708.5 & SICC Ch. 16
Seismic Resistance Electrical NC Building Code 1705.3 para 2- 5, 1707.8,
Components Y 1707.9, 1707.10, & 1708. 5 & SICC Ch. 16
Structural Observations required in sER NC Building Code 1702 & 1709 To be
Occup Category III or IV per Table y conducted by the Structural Engineer of
Record
Special Cases U NC Building Code 1704.13
* INSPECTION AGENTS Name, Company, Address
1. Special Inspections Engineer of Record 1: 3v t I6+h STR.
i�sg�W- �C'N>DG�L Ee.s OIaR�c.lN�i U-P tjay. GorWe r
2. Inspection and Testing Agency 1 A: Z�d113
K etc. A. , Se Ccnaef_4&)h. S LLP �` «
3. Special Inspections Engineer of Record 2:
4. Inspection and Testing Agency 2 A:
5. Special Inspections Engineer of Record 3:
6. Inspection and Testing Agency 3 A:
Note: The inspectors and testing agencies shall be engaged by the Owner or the Owner's Agent, and not by the Contractor or Subcontractor whose
"work is to be inspected or tested. Any conflict of interest must be disclosed to the Building Official, prior to commencing work.
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SICC 2009 - Appendix A Blank Forms
Page 3 of 3 CATAWBA COUNTY, NORTH CAROLINA
r
STATEMENT OF SPECIAL INSPECTIONS
' Identification of Seismic Systems NCBC 1705.3
Seismic Design Category p
Identification of Seismic S stems Required
NCBC 1705.3 pars 1 & 1705.3.1 Description of seismic force resisting system requiring special inspections
(Review Section 1705.3, 1707 and 1708 of the NCBC to prepare this section):
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TLv 525 A' � D flow: SNe a - tiA NG
NCBC 1705.3 para 2 & 1705.3.1 Description of designated seismic systems requiring special inspections
(Review Section 1705, 1707 and 1708 of the NCBC and ASCE 7 to prepare this section):
NCBC 1705.3 para 3, 4, 5 & 1705.3.1 Description of additional seismic systems requiring special
inspections (Review Section 1705, 1707 and 1708 of the NCBC and ASCE 7 to prepare this section):
Identification of Wind Force Resisting System 1705.4
Basic Wind Speed 3 second gust)
Wind Exposure Catego
Identification of MWFR Systems Required Y/N _ .
Description of wind force resisting system and designated wind resisting components requiring special
inspections (Review Section 1705.4 of the NCBC to prepare this section):
AJ 4
Statement of Responsibility
List each contractor responsible for the construction or fabrication of a system or component designated above. Each
contractor listed must submit a Statement of Responsibility.
Name Company System or Component
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o M GW1 i 1 -a4 f 4D.• V M ASSN Z
t11A11J Ce - M^L uCgna 4- a4 taC
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