HomeMy WebLinkAbout1 LEGOLAND DR; RETAIN; CB973400; Permit' '
BU_! LO ING PERMIT Permit No~ CB97340d: .
Project ·No: 'A940113{6'.
;pevelopment No: .DEV:94.003 -
11/07 /97 11: 09,
Page 1 of 1 ·
Job Addre$s:
-. -
Suite: 1254 ll/07/97 0001 01· · 02 Pe-rtni t Type : RETA!NING WALL
Parcel No: 211-.010-24~00 Lot#: C-PRMT . 135,!<00 ·
Valuation: . · 5,1134 -
Occupancy· Group: Reference#:
: .Construct·io:n. TY_fi-e: VN
Status:. ISSUED.
· Desc+iption·: · 384 SF RE'l'A.'.l:NING WALLS At.ONG
: p; A. R. ' "LE.GO LAND Ii
. AppJ,.ied :_ 11/06/97 ·
Apr/Issue.: 11/_07/:97 ·
'Ente:red :Sy: MDP
619 753-282.4
:,
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CITY OF CARLSBAD -. .
2075 Las Palmas :Or-.,. Qu-lsbad, CA·92009 (619) 438-1J61
. ' .
' ... -·~·-
· FOR OFFICE USE ONLY .
PLAN CHECK NO. q 7,5 Lf6 o PERMIT APPLICATION
CITY OF CARLSBAD BUILDING DEPARTMENT
2075 Las Palmas Dr., Carlsbad CA 92009
(760) 438-1161
-EST. VAL.------------
Plan Ck. Deposit d4=:
Validated ~Y • __:___,___
Date,--:-,-,,-...... (1,-1:,-( 4--{ 7-1-. ~{ f/E-7+-' -· _
Legal Description Lot No. Subdivision Name/Number Unit No. Phase No. Total I of units
Assessor's Parcel I , Existing Un Propoeed Uii
0?>4:ft OF i2f;m1 b 1l?O> W/.l\..l,, -. ----,
Description of Work SO. FT. lot Stories I cif Bedrooms · I of Bathrooms
'2. ·:coNTACt PERSON ilf dlfteiinflniin applcantj_.
Name Address ·City· State/Zip elephone I
:h\;(&4~00'/ Of: Omii~'7fl:T~";~;,;~ ,;~:'""'''c'f,,;c;-~"'.: :· r•,.-,
Address Telephone
State Licens! I ________ _
6 •. WORKERS' COMPENSATION ...... ·.· .· .. ,. -.· • . . . . """'." ; '.· .. _'· . ·:>; ,;;-::. .. · ~·:,·,,I':?:·:.·,;::;::: .. ;;;;-..,:~ ':;.~1-r.;. -·._-. ···,·. ··,···.-·. ··;."· ·
Workers' Compensation 0ecl1r1tion: I hereby effirm·under penalty of perjury one of the follow,ng dect1iltions: .
0 I have end will maintain a certi_ficete ,of consent to self-insure to·r. workers' compensation es ·provided by Siction 3700 of the Labor Code, for the performance
· -of the work for which this permit is issued.
0 I have end will maintain workers' compensation, 1s required by Section 3700 of-the Labor Code, for the-pertorin1nce of the work tor which this permit. is
issued. My worker's compensation insurance carrier 1nd·policy number are: . . "" ~ / /
Insurance Companv-, PHJ,J ''fi .. (@NWAM .f Cb, .. . Policy No.z2.41 I '2-£.3 Ok Expiration Date 119%'
(THIS SECTION NEED NOT BE C0MPLmD IF lHE PERMIT IS FOR 0NEHUNDRED·D0~RS lt100J OR LESS) ' I
0 CERTIFICATE OF EXEMPTION: I certify that iii-the performance of the work for which this permit.is i11ued, 1·1.hell not employ·1ny person in any m1nner IC> IS
' Compensation Lews of C11ifomi1.
J'.Sltffl!Plfl..Slon conrage la unlawful, age! nll subject en employer to c:rlmklal penaltla end clvll fin11 up to 111M hundred
of cornpffllltion, dlfflllllN • provided for In Section :,7oe· of • lnt-t end attorney's fN1.
·DATE q
I hereby affirm that I m exempt from th• Contractor's Liceri11 Law for the.followjng reason:
0 I, as owner of the property or my employHs· with w1g11 IS their sole compensation, wJII do-the' work ind the ·structure is not intended· or offered for 11le
(Sec. 7044, Business and Professions Code: The Contr1ctor'1 License Law dou not.apply to •n owner of property who buildl or improv1S thereon, and who doff
such work himsalf or through his own employHs, provided thlt ll!Ch Improvements are not intended or offericl for 11la. If, however, the building or Improvement II
sold within one year of complation, the owner-build"r will have the burden of proving thlt he did ncit build or Improve for tlle purpo11 of 11lel.
0 I, as owner of the property, 1m exclusJvely contrai;:ting with licensid contractors to construct the projict (Sec;. 7044, Busineis and ProfHlions Code: The
Contractor's Licensa Law does not apply to 1n owner of property who builds or improvn thereon, and contract, for such projects with contr1ctorlsl llcenaed
pursuant to the Contra·ctor's Lic11n11 Law). ·
0 I am exempt under Section ________ Business •nc! Profe11ions (;ode for this. rH1on:
1. I personally plan to provide the major labor •nd m1t1ri1ls for·construction of the propo11d·property improvement. o. YES ONO
2. I (have/ have not) signed an application for I building permit for the·propo11d work.
3. I have contracted with the following person (firml to· provide the proposed construction (include· name / 1ddrlli / p~ number / contractors license number):
4. i plan to provide portions cit the work, but I have hired the fc,llowing person to coordinate, 1upervile and provide the major work (Include name / 1d~ress / phone
number / contractors licensa number): · . .
5. I will provide some of the work, but I have contracted (hired) the following peraons to provide the work Indicated (include name/ 1ddre11 / phone number/ type
of work):, ________________ +------------------------------------------,--'------
PROPERTY OWNER SIGNATURE------------------------,----,.---DATE __ ...,., ____ .,... __ _
'COMPLETE THIS SECTION FOR liON-RfflDBnw: IUli.biNG PERMrri'oNtf;·~~£~:·0' 1 ~ -~·:t-·.,:!-'.:.1'~~:,T~~i:::;~'.~rr~'.~"':·~~-~~'r,.q-zi~::;t-:·~:·:· c:, .,i: ·, ... ;r,7:··-~~~~-:·: ·-:~: ..
Is the _applicant or future building occupant required to submit I business P,l1n, acutely hazardous m1teri1ls registra~ion form or risk management end prevention
program ~nder Sections 25505, 25533 or 25534 of the.Presley-Tanner Hazlirdous Substance Account-Act? 0 YES O· NO
Is the applicant or future building occupant required to obtain I permit from.the air polluticm control distri_~ or1ir quality m1n1geinerit district? 0 YES O NO
Is the facility to be constructed within 1,000 feet.of the outer boundary of ,,ichool iite7 0 YES O NO
IF ANY OF THE ANSWERS ARE YES, A FINAL CERTIFICATE OF OCCUPANCY MAY NOT BE ISSUED UNLESS THE APPLICANT HAS MET OR IS MEETING THE
REQUIREMENTS OF THE OFFICE OF EMERGENCY SERVICES AND THE AIR POLLUTION CONTROL DISTRJCT. .
rs. ·· coNsmucTioN· i.i:NoiNG AGi!Mcv.· '" -,,M.,,,~ ·"'?7:-:":'.'.:'"'::':f ':':'·:.::,:.,f'?:.1?7:TI'':::~~~,'.'""-:'1''"'~!-.,.,.:-"!"''·''"':'.:"'::':::'"'..,.-,., M,· ~ ·:; · ,,,..,. ····, .,,,..,.--: -· ·:·
I hereby affirm that there is a construction lending agency for the performance.of the work· for which this permit is issued (Sec. 3097(i) Civil Code).
LENDER'S NAME _______________ _ LENDER'S ADDRESS-,,,-:,----,,--,-------,-----------------
f9;· . APPLICANT CERTIFICATi0N :';,·,::-·,,· .. :~ ',·,;•··.;=~·:"7°::-:·~":'"""":'.":0~~;:-~'~;.,."_'"."::..~,:_,:;~·itt:ll-·,:1~,;:,,~'E;r'_:,.,! '..;~t.'--,,i,:li:1":".:=-~r.;:;?;f;':"""<''"''".1· ':h"···. ·· • ·. ;:··, .... ··· ,., : ·r• '
I certify that I have read the application and state that the above· information is correct and thit the informition on the plans is accurate. I agree to comply with 111
City ordinances and State laws relating to building. construc;tion. I ~reby Juthorize represent1tivn of the Citt of ,Carlsbild to enter upon the above mentioned
property for inspection purposes. I ALSO AGREE TO SAVE, INDEMNIFY AND KEEP HARMLESS THE CITY OF CARLSBAD, AGAINST ALL LIABILITIES,
JUDGMENTS, COSTS ANO EXPENSES WHICH MAY IN ANY WAY.ACCRUE AGAINST SAID CITY IN CONSEQUEN,CE"0F THE GRANTING OF THIS PERMIT.
OSHA: An OSHA permit is r or excava · s over 5•0• deep and demolition or construction of st,ructures over 3 stories-in height.
EXPIRATION: Eva,.,. rmit issued by the Buildin O icial under the provisions of this Code shall expire by·limitation arid become null and· void if the ·building or
work authorized such permit is not comma . d · 65 daysfroni the dlt!I of such-permit or, If the building.or wqrk authorized by·such permit is·suspended
or abandoned at any time aft r thew o d for-period of 1,80 d1ys.(Section _106.4.4 Uniform Buildin~ Code). / _· J , .
. . · . • DATE I I 7 l4 J . --'-j,~.....,,-...... '---·----
PINK: Finance
. ·--------.
Inspection List·
Permit#: CB973400
Date Inspection Item
12/26/97 69 Final Masonry
12/22/97 69 Final Masonry
12/8/97 66 Grout
12/5/97 66 Grout
11/24/97 61 Footing
11/21/97 61 Footing
11/19/97 61 Footing
Monday, May 24, 1999
Type: RETAIN
Inspector Act
PK NR
PK co
PK SW
PK CA
PK AP
PK co
PK· NR
384 SF RETAINING WA_LLS ALONG
P.A.R. "LE:GOLAND"
Comments
NO PL,ANS-NO·CARD TO SIGN
BY PAT K-NOT READY@ 8:0
l.,EFTNOTICE
P~ge 1 of 1
..
CITY OF CARLSBAD BUILDING JOB ADDRESS M . -~~ . ':f'-J/2 1-{;/t!P~ /4 ~ 4J
•
' . • .. NOTICE m~ ~.,,, .... ..
I OWNER OR PERMITTEE NAME
D VIOLATION
NOTE:
READ
REVERSE
SIDE
PRESENT THIS NOTICE WHEN
MAKING APPLICATION FOR PERMIT
D CORRECTIONS REQUIRED
O PARTIAL APPROVED
INSPECTION @ DEPARTMENT CENUS TRACT NO. '\ I PERMIT NUMBER'~ I ,)'LAN FILE NUMBER
00501 .. t:1/-:J-S ~t::J
. .
NO. CONTRACTOR
/2E' $) 4/14/?t:J
MAiL ADDRESS FOR I DOWNER, OR
D CONTRACTOR
D NO PERMIT -STOP WORK -REMOVE CONST:RUCTION, OR OBTAIN PERMIT AND MAKE ANY
WORK COMPLY WITH BUILDING LAWS. (See comments on reverse side regarding penalty fees).
D CONSTRUCTION NOT IN ACCORDANCE WITH APPROVED PLANS AND PERMIT -STOP WORK
MAKE EXISTING WORK COMPLY WITH APPROVE;D PLANS AND PERMIT OR REMOVE IT.
D CALL PLANING DEPARTMENT AT 430:1161, CONCERNING VIOLATION OF ZONING
REGULATION LISTED BELOW.
STOP WORK -UNTIL AUTHORIZED TO CONTINUE BY THE INSPECTOR.
0 CONTACT CODE ENFORCEMENT OFFICER AT 438-1161.
D
D
D
' CONTACT INSPECTOR AND ARRANGE FOR APPOINTMENT AT 438-3550.
CORRECTIONS LISTED BELOW MUST BE MADE BEFORE WORK CAN BE APPROVED.
.PAV REINSPECTJON FEE (See Back); THEN. 0 CALL FOR RE;INSPECTION AT 438-3101.
0 WORK DESCRIBED BELOW HAS BEEN INSPECTED AND IS APPROVED.
THE ACTIONS OR CORRECTIONS INDICATED ABOVE ARE REQUIRED WITHIN,---~ DAYS. THE CARLSBAD
MUNICIPAL CODE REQUI ES PENALTY FEES WHEN WORK HAS BEEN STARTED WITHOUT PERMIT. ., ~ BUILDING
INSPECTOR'S SIGNATURE
IN-13 (Rev. 2/86)
7:00 A.M. TO 8;00 A.M.
3:00 P.M. TO 4:00 P.M.
- . ;•. ' ' .. M~t4DAY !ti,~~. f.'~JD~Y· ,' '
·EL~CTRICAL
H~TING
PLUMBING
REFRIGERATION
COMBINATION
BUILDING INSPECTION DEPARTMENT GENERAL REQUIREMENTS
1. No person, firm or corporation shall erect, construct, enlarge, alter,
repair, move, improve, remove, convert, or demolish any building or
structure in the city, or cause the same to be done, without first
obtaining a separate building permit for each such building or struct-ure from the Building Official. Uniform Building Code Sec. 301.
Where work for which a permit is required by this Code Is started
or proceded with prior to obtaining said permit, the fee schedule
established by the city shall be doubled, but the payment of such dou-ble fee shall not relieve any persons from fully complying with the re-
quirements of this Code in the execution of the work nor from any other
penalties prescribed herein. Uniform Building Code Sec. 304.
2. When the Building Official issues a permit, he shall endorse In writing or stamp on both sets of plans and specifications "Approved." Such approved plans and specifications shall not be
changed, modified, or altered without authorization from the
Building Official, and all work shall be done in accordance with the
approved plans. One set of approved plans and specifications shall
be returned to the applicant, which set shall be kept on such
building or work at all times during which the work authorized
thereby is In progress. Uniform Building Code Sec. 303.
3. A building permit shall expire and become null and void if the build-
ing or wori<.authorized by such permit is not commenced within 180
days from the date of Issuance or if the building or work authorized
by such permit is suspended or abandoned at any time after the work
Is commenced for a period of 180 days. Uniform Bldg. Code Sec. 303.
4. No work shall be done on any part of the building or structure
beyond the point Indicated In each sucessive inspection without
. first obtaining the written approval of the Building Official. Uniform
Building Code Sec. 305."
5. Whenever any building work is being done contrary to the provision ·
of this .Code, the Building Official may order the work stopped, and
any such persons shall forthwith stop such work until authorized by
the Building Official to proceed with the work. Uniform Building
Code Sec. 202.
6. No electric wiring, devices, appliances or equipment shall be
Installed within or on any building, structure or premises nor shall
any alteration or addition be made In any such existing wiring,
devices, a,ppllances or 1equipment without first securing a permit therefor from the Inspect on Department except as stated In Ord. No.
N527. In addition to any other penalty provided In this Article for viola-
tions thereof, any person who has done any electrical work .without
permit as required by this Article, or who has caused.any such work
to be done-without a permit, shall pay a Penalty Fee In addition to the
regular permit fee for Inspection of such work.
7. No plumbing system or part thereof regulated by this Code shall be Installed within or on any building, structure, or premises, nor shall any
alteration, addltio~ or replacement, be m13de fn ·any such existing plumbing system unless a permit therefor has first .-be~n
Issued by the Inspection Department except-as stated In Ord: No. 8109.
8. No heating, ventilating, air conditioning, or refrigeration system, or part
thereof shall be Installed, altered, replaced, or repaired unless a 'per-
mit therefor has first been issued by the Inspection Department, except as stated in Ord. No. 8108.
9. Relnspectlons. A reinspection fee may be assessed for each Inspec-
tion or relnspection when such portion of work for which Inspection Is called Is not complete or when corrections called for 13re not made.
Reinspection fees may be assessed when the permit card Is not pro-
perly posted on the work site, the approved plans are not readily
available to the inspection, for failure to provide access on the· date
for which Inspection is requested, or for deviating from plans requir-ing the approval of the Building Official .
· I~ Instances where reinspectlon fees have been assessed no addi-
tional inspection of the work will be performed until the required fees · have been paid. Excerpts from U.B.C. Sec. 305.
PLEASE DIRECT INQUIRIES REGARDING REQUIREMENTS FOR OBTAINING A PERMIT
TO THE PERMIT COUNTER, 438-1161
1. Applications for permits are processed at 2075 Las Palm as Dr. Permit
applications are not accepted via mail without prior arrangement. ,
The information identified in items 2 & 3-below must be submitted at the time of application for permit.
2. The State of California Labor Code Section 3800 mandates that no person, owner or contractor shall employ any person, In any manner,
in conjunction with a construction project for which a permit is required unless such employer shall first have in force a Workmen's Compen-sation Insurance Polley.
(a) A CE!rtlficate of Insurance, as required by State Labor Code Section · 3800, must be presented prior to the issuance of required permits unless such Certificate is already on file with the Building Inspection Department.
(b) It Is extremelr important that the Certificate of Insurance be issued
to the City o Carlsbad and must contain a clause stating that In
the event the insurance is cancelled, 10 days prior notice will be
given to the City of Carlsbad.
(c) The requirement for presenting evidence of Workmen's Com-
pensation insurance coverage is waived for the property owner who Is performing all worK himself, and also for contractors
who do not employ o\her persons to perform any work. A
~ ..... --
certificate of non-employment must be signed, ·and owner
verification form completed, by the property owner when· making application for any \ype permit.
3. In addition to. the requirement of item 2 of this section, it will be · · necessary to provide the following Information when submitting a Plan
Check Application. ,
(a) the legal description of the property (lot number, block number,·
and name of .subdivision). ·
( b) two plot plans, three if commercial property, drawn to.scale, wh)ch
indicate the following:
(1) shape and size (dimensioned lengths of lot ·boundaries} of
the property.
(2) shape and size of all buildings presently on -the lot Including the proposed constructldn requested by this permit application, and · .
(3) the location (dimensioned distances) of all buildings from
adjacent property lines and from each other.
(c) Two sets of construction plans drawn to scale whlQh,clearly show
that the proposed work will conform with the requirements of the
City of c;:arlsbad. Three sets if comm.erclal property.
Date: 8 December 1997
To: Memo to file PAR
From: Principal Building Inspector
Re: Sequence of events for work done w/o inspection.
Rob w/ RE Hazard called and requested a Friday AM. inspection for grout. I gave
the request to Pete. While driving past the site at 8:30, I observed they were still
setting block. I called Pete and canceled the inspection. The contractor called at 2
p.m. and said he was now ready, and I told him I had no one to dispatch to that call. I
told him that in my opinion, the wall would not stiffer in a raih. Rob chose to grout the
walls w/o an inspection at about 4:00 p.m. because of the threat of rain. While
driving home Friday I observed the masons still laying block on the most westerly
wall. The two easterly walls had been grouted.
I delivered the attached correction notice to the contractor Monday morning.
Principal Building Inspector
• Page 1
CITY OF CARLSBAD
INSPECTION.REQUES':;!:'
PERMIT# CB973400 FOR 12/05/97
DESCRIPTION: 384 SF RETAINING WALLS ALONG
P.A.R. "LEGOLAND"
TYPE: RETAIN
JOB ADDRESS: O
APPLICANT: HARRISON, STEVE
CONTRACTOR:
PHONE·:
PHONE.:
STE:
INSPECTOR AREA PK
PLANCK# CB973400
OCC GRP·
CONSTR. TYPE VN
LOT:
OWNER:
REMARKS: C/BOB/899-1478
SPECIAL INSTRUCT: INSPECT
619'753~= . _(}_
INSPECTOR ~ PHONE:
..,......----,--------.-----BEFORE NOON PLEASE.. THE CARD. IS AT THE EAST WALL
TOTAL TIME:
CD LVL DESCRIPTION . ACT COMMENTS
-66-_MA _G_r_o_ut----------,-.,.........__,....,___,,...-.....,.. _.ar_· .. ·. . ft &z J:;-cc
-----------....--------------------------.......,...---,-------
DATE
112497
112197
111997
DESCRIPTION
Footing
Footing
Footing
***** INSPEC,:PION HI$.TORY *'!t***
ACT INSP
,AP PK
·CO PK
NR PK
COMMENTS
LEFT NOTIC~
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r . • '1 ,.. HAZARD COMPANIES
P.O. BOX 229000 • SAN DIEGO, CALIFORNIA 92192 e PHONE 587-3600
MEMORANDUM
7
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IT IS BETTER TO WRITE IT FORGET IT
FORM 2010
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619-675-0083 lJYMAt,1 TEST! HG LAB
Wyman
Testin,g
Laboratories
COVERING WORK PERFO~MED WHICH O REINFORCED CONCRETE O FIELD WElDING
REQUIRED ~PPROVAL BY THE SPECIAL O PRE·STRESSED CONCRETE O H.S. BOLHNG
INSPECTOR OF O REINFORCED MASONRY O SHOP WELDING
622 P0~i DEC 15 '97 09:51
(619) 675~0270
0 FIREPROOFING O S~~E
0NDT ~HER
0 D/8 AN1:::HORAGE
FO~ WEEK I ., _ Lf EN.Ol~IG .... 19
-Pl.AN FILE NO,
INSP1N
DATE
LOCATIONS OF WORK INSPECTED, TEST SAMPLSS TAKEN, ETC., Includes intormotlon obout amounts of materiol ploced
or work pel1ormed: number, type, and identity numbers of testsamples taken; structurol :onnectlons (welds, tl.t, bolts
torques) checked: etc.
'
J.------l-........... ~:..,.,.M:~_,__~ir...ac..'-----'~~1.la:~.#Zf...-..~_--L..,C#--.Jl:..:L.~~~11 s WAJ 'AL 0LlA,v
c::
APPROVAL SIGNA'fURE: -------~-.......... -
PRINTE[) NAME:
C~f?TIFICATION OF COMPLIANCE
619-675-0083 WYMAH TEST! HG LAB
Wyman
Testing .
Laboratories
COVERING WORK PERFORMED WHICH
REQUIRED APPROVAL BY THE SPECIAL
INSPECTOr.• OF
JOB AOORiSS
OWNER OR •l"lOJECT NAME
CONSTR, MAT'l (l'YP~. GRAO!f. ETC,l
0 REINFORCED CONCRETE O FIELD WELOING
0 PRE-STRESSED CONCRETE O H.S. BOLTING
0 REINFORCED MASONRY o· SHOP WELDING
9~DG. PERMIT NO.
ARCHITECT
DESIGN STRENGTH SOVRCE OA MFGR.
CONTR, POI
622 F'8ti DEC 15 '97 09:52
(619) 675-0270
0 FIREPROOFING O S~CRETE
0 NDT (iX)THER
· 0 D/B AMCHORAGE
FOR WEEK "'\
ENDING ft...,,_..,J. 19
LOCATIONS OF WORK INSPECTED, TEST SAMPLES TAKEN, ETC., Includes lnformotlon obot.. f amounts of moterlCll placed
or work performed: number, type, and Identity numbers of testsamples taken; structure I connections (welds. h.t. bolts
torques) checked; etc.
L_
APPROVAL SIGNATURE:---------~...-
PRINTED NAME: QA O A & §15 i'l :::: ..
CERTIFICATION OF COMP~fANCE
11ME IN:·
TIME OUT:
INSPECTOR
I 11rnrnv r'FnTIFY THAT I HA\/F INSPFi:TFf) All t'1F THE ABOVE RF.PO.RT~[) WOR!{, ~Nl~SS r··
.fr."' llnd
l ./J,t(C 4,1/i
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619-675-0083 lJYMAH TEST! HG LAB 622 P0'' DEC 15 '97 09:53
Wyman
Testing
Laboratories (619) 675 .. 10270
C0V~RING WORK PERFORMED WHICH 0 REINFORCED CONCRETE tJ FIELD· WELDING 0 FIREPRO()FING ~CRETE
REQUIRED 11PPR0VAL BY THE SPECIAL D PRE·STREssgo CONCRETE 0 H.S. BOLTING ONDl OTHER
INSPECTOR OF 0 REINF0RCl:D MASONRY 0 SHOP WELDING 0 D/B ANCHORAGE
JOB ACOR~SS NO, q7., ~ ! '-1-IFOJ'l WEEK . ". llNDtNG 1 19
OWNER OR PUOJECT NAME
,_ • I '"" •_
6~0G. PERMIT NO. jPLA,tJf ~ .?o.
CONSTA. MAT'. {TYPE, Gl'tAD~. ~t;,l l ~ ~ ARCHITE;CT
I """ OESIGN ST!tel\.GTH ~ ,,.-1 e,, I SOURCE .OR MF~!'!. ENGINeeR t., -~ A"" .
O~SC!'l18!. MAT':tttpt.SltN. l'le-BAR GMOE & Ml'G!t GEN!.iRAL c,,of fl-Cf'OR
(' ·CONTt'l, Dql!NG l'lEPORTeC> WORK
[ii LOCATIONS OF WO~K INSPECTED, TEST SAMPLES TAKEN, ETC., includes information about amounts of material ploced
or 1.1,ow. r.:,~rformArl: n, ,mhAt. ~-ond idenfitv numbers of testsqmples token; structural ,~onnectlons {welds, h. t. bolts
torques) checked; etc.
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PRINTED NAME: !J9 o~~ &-,~..) ::::: . INSPECTOR S:/LvE PDJA~t II
CERTIFICATION OF COMPLIANCE ~ ~~ .. --~~J{J HEREBY CERTIFY THAT I HAVE INSPECTED ALL OF THE A80VE REPORTED WORK. UNLES
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