HomeMy WebLinkAboutCBPR-5-11-10809 Statement of Special Inspections.tif s
Page 1 of 3 CATAWBA COUNTY, NORTH CAROLINA
Appendix A Blank Forms
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SPECIAL INSPECTIONS PROGRAM
Statement of Special Inspections
TPI Permit #1: TPI Permit #2: TPI (TPI Permit Numbers to be furnished Permit C #3
PROJECT: rJt)tJW -'� tom �Q -�l'IO �" 10? t t Z�w1 Y BSD)
NCBC Edition: 2
Address:
Occupancy: s AJ��6
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onstruction Type:
Building Owner:
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Name
Owner's Address: Company
Architect of Record: -A k(C- b A y i e � r{
Name License b � �( ��' •�
Structural Engineer of Record: Company
(az-� � la tw- (2� �' 71� u Fje( Company n. �tA.
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Name & License
Geotechnical Engineer of Record: V4,L �3s
Name Of License
Special Inspections Engineer of Record 1 : A 0 -<Q LG 4 . Company /� b
Name &License (�"�`_ L L T
Company
Special Inspections Engineer of Record 2:
Name &License
Company
Special Inspections Engineer of Record 3:
Name &License
Company
General Contractor: l IaJ64fVrn� �l.�G• 21S2L
—a Name & License r lueh ' <:::6 f
This Statement of Special Inspections is submitted as a condition for permit issuance in accordance w' Company
Building Code. with the North Carolina Statewide
The Special Inspections Engineer of Record shall keep records of specified special inspections and testing
inspection and testing reports to the Catawba County Building Services Division and to the a
of record. Discrepancies from the a 9 rid shall famish copies of
pproved plans and specifications and code violations observed during g the conduct des
of spec alsionals
inspections services shall be brought to the immediate attention of the contractor for correction, to the attention of
Building Services Division, and to the appropriate registered design professionals of record. A final report of s pecial inspections
documenting completion of specified special inspections and correction of any discrepancies and observed the Catawba County x
inspection and testing reports shall be submitted to the Catawba County Building Services Division prior to the request for final building
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inspection and building inspection approval by County staff.
Prepared by Registered Design Professional in Responsible Charge:
(Type or print) Name 1(
Signature & Date
Building Owner's Authorization:
Si nature & Date
Building Official's Acceptance:
Catawba County Building Services Signature WD
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SICC 2009 - Appendix A Blank Forms
FF STATEMENT OF SPECIAL INSPECTIONS
n Date:
r pared By: TIVITY /SY STEMS Y/N AGENT * Continuous or Periodic Ins ection ref. below
tion, Fabrication & tance NC Building Code 1704.2, 11707,
truction, Fabrication & 1708.4 &SICC Cha ter 6
Seismic Resistance 4/ NC Building Code 1704.2, 1704.4, 1708.3
Masonry Construction, Fabrication & SICC Chapter 7 & 8
Seismic Resistance- NC Building Code 1704.2, 1704.5, 1708.1 &
Wood Construction, Fabrication & SICC Cha ter 9
Seismic Resistance NC Building Code 170 1707.3
Soils & SICC chapter 10
Pile Foundations & Fabricators NC Buildin Code 1704.7 & S,ICC Ch. 11
u NC Building Code 1704.2, 1704.8, 1808,
Pier Foundations 1809, 1810, 1811 & SICC Section 1104.2
• NC Building Code 1704.9, 1808, 1812 &
Earth Retention S stems SICC Section 1104.2
Sprayed Fire Resistance Materials NC Buildin Code 1806.2 & SICC Ch. 12
Mastic &Intumescent fire - resistant coatings NC Buildin Code 1704.10 &SICC "Ch. 13
EIFS NC Buildin Code 1704.11 &SICC Ch. 13
Smoke Control NC Building Code 1704.12 & SICC Ch. 14
Seismic Resistance Architectural, N NC Building Code 1704.14 & SICC Ch. 15
Com onents NC Building Code 1705.3 Para 4.2, 4.3, 4.4,
Seismic Resistance Mechanical 4.5, &1707.7 & SICC Ch. 16
Com onents NC Building Code 1705.3 Para 2- 5, 1707.8,
Seismic Resistance Electrical 1707.9, 1707.10, & 1708.5 & SICC Ch. 16
Com onents NC Building Code 1705.3 Para 2- 5, 1707.8,
Structural Observations re wired in Y 1707.9, 1707.10, & 1708. 5 & SICC Ch. 16
Occupancy Category III or per Table sER NC Building Code 1702 & 1709 To be
1604.5 Y conducted by the Structural Engineer of
Special Cases Record
INSPECTION AGENTS
NC Building Code 1704.13
* Name,
1. Special Inspections Engineer of Record 1: Company, Address'
Gklo u-P tit tV Gor.�vd l�l:
2. Inspection and Testing Agency 1 A: Z�d113
etc. p►.
lie. Cfa LLP t` u
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
STATEMENT OF SPECIAL INSPECTIONS
Identification of Seismic Systems NCBC 1705.3
Seismic Design Cate o p
Identification of Seismic systems Re uired
NCBC 1705.3 Para 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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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 S eed 3 second gust
6 nhP1�
Wind Exposure Catego
identification of MWFR Systems Require 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):
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Statement of Responsibility
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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 S stem or Component I
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