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SPECIAL INSPECTION REPORT
DISCREPANCY KcCINFORMANCE
All discrepancies shall be brought to the immediate attention of the All work conforms to approved design and code requirements, submit
Contractor for correction. If corrections are not made in a timely this report to the Building Department and copies to Contractor, Engineer
manner, this report shall be used as a discrepancy notice. Submit the or Architect of record and Owner no later than the business day following
original to the Building Department and copies to the Contractor, the conclusion of the special inspection. For inspections greater than 5
Engineer/Architect of record and Owner. days duration, submit a status or progress report at least once a week.
This is a (check one) Progress Recort Final Report Report No.:
Project Address:
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Description of Project:
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Permit Number-,
Owner:
Archlttect/Engineer of Record:
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Contractor.A
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Full Name of Special Inspector.
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Registration Number & Expiration Date
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Company:
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Phone Number:
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Type of Inspection:
17.1 Reinforced Concrete []Structural Masonry ❑Piling, Piers and Caissons ❑Smoke Control
L1 Prestressed/Post-tensioned ❑Bolts in Concrete/Masonry qExcavation and Fills ❑Energy Compliance
❑Shotcrete/Gunite ❑Structural Welding ❑Spray -Applied Fire Proofing ❑High Load Diaphragms
I] Insulating Concrete/Gyperete []High Strength Bolting Ather y
Time Time
Date Arrived Departed Description and Location of Work Inspected
I HEREBY DECLARE THAT THE FOLLOWING IS TRUE TO THE BEST OF MY KNOWLEDGE:
1, 1 HAVE ALREADY BEEN PRE REGISISTERED AND APPROVED BY THE LOCAL JURISDICTION. I HAVE FIRST CHECKED IN WITH THE
LOCAL BUILDING & SAFETY OFFICE BEFORE REPORTING TO WORK AND PRIOR TO CONDUCTING INSPECTIONS AT THIS PROJECT.
2. 1 AM OR MY COMPANY IS, RETAINED BY THE OWNER OR THE ARCHITECTIENGINEER OF RECORD TO PROVIDE SPECIAL INSPECTION
FOR THE WORK COVERED IN THIS REPORT.
3. [HAVE PERFORMED THE REQUIRED INSPECTION DURING THE TIME PERIOD AS STATED ABOVE,
4. THE WORK COVERED IN THIS REPORT IS IN CONFORMANCE TO THE APPROVED PLANS, SPECIFICATIONS AND APPLICABLE
WORKMAN ROVISIONS OF THE CODE, EXCEPT AS INDICATED OTHERWISE./'Aevell
Print Name PG.1 L�-�� Lic�#/NNGJ `J W3
Signature- a-6 to (Revised 10/2011)
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2004 Ili a Cct'on
Project Name: (� a
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Project No.: Date: 1112-1,2419"
Location:
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Permit/DSA/OSHPD #. (LEA #204):
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To:
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Subject:
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M�aGeotechnicalEnvironmental
DHydrogeologyMaterial Testing
Construction Inspection
3037 S. Harbor Blvd., Santa Ana, CA 92704
Ph: 714 641-7189 Fax: 714 641-7190
MEMO
Signed By:
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Print Name: