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HomeMy WebLinkAbout1772 FAIRLEAD AVE; ; CB112520; Permit04-30-2012 Job Address Permit Type Parcel No Valuation Occupancy Group # Dwelling Units Bedrooms Project Title City of Carlsbad 1635 Faraday Av Carlsbad, CA 92008 Residential Permit Pemriit No.CB112520 Building Inspection Request Line (760) 602-2725 1772 FAIRLEAD AV CBAD RESDNTL Sub Type CONDO Status ISSUED 2150203302 Lot# 2 Applied 10/19/2011 $114,069 00 Constuction Type 5A Entered By RMA Referenced CT04010A Plan Approved 04/30/2012 1 structure Type MF5+ Issued 04/30/2012 0 Bathrooms 0 Inspect Area OngPC# PC110053 Plan Check # VITALIA FLATS/CONDO - UNIT 2 1ST FLOOR - BUILDING #9- UNIT TYPE Bl, 956 SF, 336 SF (DETACHED IN A SEPARATE GARAGE B)UILDING, 115 SF BALCONY. 25 SF STORAGE Applicant SHEA HOMES INC ATTN SARAH BECKMAN STE 200 9990 MESA RIM RD 92121 858 526-6554 Owner SHEAHOMES INC STE 200 9990 MESA RIM RD SANDIEGO CA 92121 858 526-6554 Building Permit $754 42 Meter Size Add'l Building Permit Fee $0 00 Add'l Reel Water Con Fee $0 00 Plan Check $528 09 Meter Fee $0 00 Add'l Plan Check Fee $0 00 SDCWA Fee $0 00 Plan Check Discount $0 00 CFD Payoff Fee $2,545 00 Strong Motion Fee $11 41 PFF (3105540) $2,076 06 Park in Lreu Fee $0 00 PFF (4305540) $0 00 Park Fee $0 00 License Tax (3104193) $0 00 LFM Fee $0 00 License Tax (4304193) $0 00 Bndge Fee $0 00 Traffic Impact Fee (3105541) $1,872 00 Other Bndge Fee $0 00 Traffic Impact Fee (4305541) $0 00 BTD #2 Fee $0 00 Sidewalk Fee $0 00 BTD #3 Fee $0 00 PLUMBING TOTAL $150 00 Renewal Fee $0 00 ELECTRICAL TOTAL $55 00 Add'l Renewal Fee $0 00 MECHANICAL TOTAL $63 00 Other Building Fee $0 00 Housing Impact Fee $0 00 HMP Fee $0 00 Housing InLieu Fee $0 00 Pot Water Con Fee $0 00 Housing Credit Fee $0 00 Meter Size Master Drainage Fee $0 00 Add'l Pot Water Con Fee $0 00 Sewer Fee $2,743 00 Reel Water Con Fee $0 00 Additional Fees $0 00 Green BIdg Stands (SB1473) Fee $4 00 Fire Spnnkler Fees $0 00 Green BIdg Stands Plan Chk Fee $0 00 TOTAL PERMIT FEES $10,801 98 Total Fees $10,801 98 Total Payments to Date $10,801 98 Balance Due: $0.00 Inspector FINAL APPROVAL Date /^ VV2 Clearance NOTICE Please take NOTICE that approval of your project includes the Imposrtnn' of tees, dedications, reservations, or other exactions hereafter collectively referred to as f ees'exactions' You tmve 90 days tran the date this permit was issued to protest imposition of ttiese fees/exactnns It you protest ttiem, you must follow the protest procedures set forth in Govemment Code Sectnn e6020(a), and file the protest and any other required information with the City Manager for processing In accordance with Carlsbad Municipal Code Section 3 32 030 Failure to bmely follow ttiat procedure wiD t)ar any subsequent legal action to attadt, review, set aside, void, or annul their imposition You are heretiy FURTHER I^TIFIED that your nght to protest the spedtied lees^exactnns DOES NOT APPLY to water and sewer connection fees and capacity changes, nor planning, zoning, grading or other similar application processing or senwe fees in connection with this protect NOR DOES IT APPLY to any fees/exadions of which vou have oreviouslv been oiven a NOTICE similar to this, or as lo which the statute of limilalions has orevioustv otherwise expired. ^^^C I T Y OF CARLSBAD Building Department INSPECTION RECORD INSPECTION RECORD CARD WITH APPROVED PLANS MUST BE KEPT ON THE JOB ^|U. PRIOR TO 4iO» P.M. FOR NEXT V|PRK DAY INSPECTION FOR BUILDING INSPECTION CALL: 760-602-2725 CB112520 1772 FAIRLEAD AV VITALIA FLATS/CONDO - UNIT 2 1ST FLOOR - BUILDING #9- UNIT TYPE Bl. 956 SF 336 SF (DETACHED IN A SEPARATE GARAGE B)UILDING, 115 SF BALCONY. 25 SF STORAGE RESDNTL CONDO Lot# 2 SHEA HOMES |NC APPROVED TO COVER DATE Type of Inspection Datp Inspector Notes BUILDING tM'Mh^ FT ^ FOUNDATION REINFORCED STEEL MASONRY • GROUT • MUALL DRAINS TILT PANELS POUR STRIPS COLUMN FOOTINGS SUBFRAME • FLOOR • CEIUNG ROOF SHEATHING EXT. SHEAR PANELS fRAME INSULATION EXTERIOR LATH INTERIOR LATH & DRYWALL ^ PLUMBING • SEU^R AND Bl/CO • PL/CO UNDERGROUND • WASTE • WATER 3^ w2. TOP OUT DWASTE • WATER 3 TUB AND SHOWER PAN • GAS TEST • GAS PIPING • WATER HEATER • SOLAR WATER FINAL ELECTRICAL • ELECTRIC UNDERGROUND • UFER ROUGH ELECTRIC WALLS 31 4 ROUGH ELECTRIC CEIUNG • ELECTRIC SERVICE • TEMPORARY • BONDING • POOL PHOTO VOLTAIC FINAL MECHANICAL UNDERGROUND DUCTS & PIPING • DUCT & PLEM. • REF. PIPING HEAT-AIR COND SYSTEMS VENTILATING SYSTEMS HNAL CALL FOR FINAL INSPECTION WHEN ALL APPROPRIATE ITEMS ABOVE HAVE BEEN APPROVED .HNAL Sign When Appropriate - Building Dept. (Inspections) (760) ^02-2725 Hre Department , (760)602-4660 Planning Department (760) 602-4602 Engineering Dept (Inspections) (760) 438-3891 BuHdlng Inspectors (7am-4pm) (760) 602-2700 c CMWD (760) 438-2722 Ext 7151 REV 8/2009 1635 Faraday Ave. * Carlsbad, CA 92008 * 760-602-2700 * www.carlsbadca gov SEE BACK FOR SPECIAL NOTES Inspection List Permlttf CB112520 Type: RESDNTL CONDO VITAUA FLATS/CONDO - UNIT 2 1ST FLOOR - BUILDING #9- UNIT TYPE 81 Date Inspection Item Inspector Act Comments 11/30/2012 308 Final gr AP 11/30/2012 69 Final Combo PB AP 11/29/2012 89 Final Combo PB NR 11/29/2012 89 Final Combo -Rl 11/27/2012 29 Final Plumbing PB AP 10/31/2012 39 Final Electncal PB AP 10/26/2012 39 Final Electncal PB AP 09/28/2012 17 Intenor Lath/Drywall PB CA 09/28/2012 17 Intenor Lath/Drywall PB AP 09/27/2012 13 Shear Panels/HD's PB AP 09/27/2012 22 Sewer/Water Service PB AP 09/27/2012 34 Rough Electnc PB AP 09/26/2012 13 Shear Panels/HD's PB WC 09/26/2012 17 Intenor Lath/Drywall PB AP 09/26/2012 22 Sewer/Water Service PB WC 09/26/2012 34 Rough Electnc PB WC 09/25/2012 13 Shear Panels/HD's PB CA 09/25/2012 17 Intenor Lath/Drywall PB CA 09/25/2012 22 Sewer/Water Service PB CA 09/25/2012 34 Rough Electnc PB CA 09/24/2012 17 Intenor Lath/Drywall PB NR 09/19/2012 17 Intenor Lath/Drywall PB AP 09/18/2012 17 Intenor Lath/Drywall PB NR 09/17/2012 18 Extenor Lath/Drywall PB NR 09/10/2012 16 Insulation PB AP 09/10/2012 18 Extenor Lath/Drywall PB AP 09/06/2012 84 Rough Combo PB AP 08/26/2012 301 Overhead Hydro gr AP 08/26/2012 303 Overtiead Visual gr AP 08/02/2012 16 Insulation PB PA 08/01/2012 13 Shear Panels/HD's PB AP 07/27/2012 22 Sewer/Water Service PB WC 07/27/2012 24 RoughTfopoui PB NR 07/26/2012 13 Shear Panels/HD's PB PA 07/18/2012 15 Roof/Reroof PB AP 07/13/2012 13 Shear Panels/HD's PB AP 07/13/2012 14 Frame/Steel/Bolting/Weldin PB WC 07/11/2012 13 Shear Panels/HD's PB CO 07/10/2012 13 Shear Panels/HD's PB PA 07/09/2012 11 Ftg/Foundation/Piers PB AP 06/29/2012 17 Intenor Lath/Drywall PB PA 06/27/2012 16 Insulation PB PA 06/12/2012 13 Shear Panels/HD's PB NR 05/29/2012 11 Ftg/Foundation/Piers MC AP RECEIVED SOILS, PT AND FORM CERT Monday. Decemtjer 03, 2012 Pago 1 of 2 05/22/2012 21 Underground/Under Floor PB AP 05/21/2012 21 Underground/Under Floor PB NR 05/15/2012 12 Steel/Bond Beam PB PA 05/14/2012 12 Steel/Bond Beam PB AP Monday, Decemtrar 03, 2012 Page 2 of 2 T>W^roHi-<^y^Southwest Inspection and Testing, Inc. 441 Commercial Way, La Habra, Ca 90631 PijUJf-^h^ 7 (562) 941-2990 • (714) 526-8441 • Fax (562) 946-0026 REGISTERED INSPECTOR'S DAILY REPORT SWIT Job No Date 1200&7- TYPE OF INSPECTION REQUIREO Reinforced Concrete Post Tensioned Concrete Q Reinforced Masonry • Structural Steel Assembly D Ftre Proofing • Asphalt • Quality Control • Wood Framing • Other Job Address Job Name City Type of Structure Permit No Architect Issued By r- r A KlM^ArJ giLC^lLcvV f^A^/j&iC, Material Descnption (type, grade, source) • - "\ Engineer Contractor Inspector's Name Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLE INSPECTION SUMMARY- LOCATIONS OF WORK INSPECTED, TEST SAMPLES TAKEN. WORK REJECTED, JOB PROBLEMS,-PROGRESS, REMARKS. ETC, INCLUDES INFORMATION ABOUT - AMOUNTS OF MATERIAL PLACED OR WORK PERFORMED NUMBER. TYPE & IDENT NO'S OF TEST SAMPLES TAKEN STRUCT CONNECTIONS (WELD MADE H T BOLTS TORQUED) CHECKED, ETC \j/yi/(/io prr . C^ijjsj-^^ S ectTt^tn Rf^ ryy.^^ t^^^n^ Sg77/^ ^^UkfuiiJ^ tn.rrf^ t^lT ^^^^^ n CERjinCAVOhi OF COMPLIANCE i HEREBY CERTIFY THAT I HAVE OBSERVED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED i HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS SPECIFICATION AND APPLICABLE SECTION OF THE GOVERNING BUILDING LAWS CONTINUED ON NEXT PAGE • PAGE ^_ OF .2^ ^"feRA^erTF I'iEGlSTER OR NO AGENCY White - OWi TIME IN TIME OUT SAMPLES Approved By 'ffice Copy • Canary - Accoun^mg Copy • Ptrik - /nspector's Copy • GoldenrodJobsite Copy Southwest Inspection and Testing, Inc. ' 441 Commercial Way, La Habra, Ca 90631 (562) 941-2990 • (714) 526-8441 • Fax (562) 946-01526= K<. / REGISTERED INSPECTOR'S DAILY REPORT SWIT Job No Date TVPE OF INSPECTION REQUIRED D---Reinforced Concrete D Post Tensioned Concrete Q Reinforced Masonry • Structural Steel Assembly Q Fire Proofing • Asphalt • Quality Control Q Wood Framing n other Job Address City Job Name Type of ^ructure-* 2M. ^ssued By ?-i) ,<^.*s. •IL Matenal Descriotion (type, grade, source)/ Engineer l(;fepector's Name , , , Contractor - / -r/ Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLE fc >7X,; Ah,;/f (NSPfCTfON SUMMARY- LOCATIONS OF WORK INSPECTED. TEST SAMPLES TAKEN WORK REJECTED, JOB PROBfcEMS^ PROGRESS. REMARKS ETC INCLUDES' INFORMATION ABOUT - AMOUNTS OF MATERIAL PU\CED OR WORK PERFORMED NUMBER. TYPE S'lDENT NO S 'OF TEST SAMPLES TAKEN STRUCT CONNECTIONS (WELD MADE H T BOLTS TORQUED) CHECKED. ETC M / J • r X 5 ^, / CERTIFICATION OF COMPLIANCE I HEREBY CERTIFY ThjAT I HAVE OBSERVED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED I HAVE FOUND THIS WORK To COMPLY WITH THE APPROVED PLANS SPECIFICATION » AND APPLICABLE SECTION OF THE'GOVERNING BUILDING LAWS CONTINUED ON NEXT PAGE PAGE- _JL OF SIGNA/URE OF REGISTERED INSPECTOR ^ NO 7 .C-C AGENCY TIME IN TIMEOUT ' SAMPLES ^. Approved By-— . ' Pfoject Supenntendent White - Office Copy • Canmy - Accduntmg Copy • Pmk - Inspector's Copy • Goldenrod - Jobsite Copy Southwest Inspectfon and Testing, Inc. 441, CommerciaKWaJ/, La Habra, Ca^0631 (562).94f-2990 • (714):526-8441 • Fax (562) 946-0026 REGISTERED INSPECTOR'S DAILY REPORT SWIT Job No Date f TYPE OF INSPECTION REQUIRED • ReinfofcedConcrete, u • Post Tensioned Concrete • Reinforced Masonry • Stnjctural Steel Assembly Q Fife Proofing • Asphalt • Quality Control D Wood Framing • Other Job Address Job Name City^ Type of Structure . ^ , / • . Architect Issued By Material Descnotion (tyoe, grade^ourcel , ' • ^ Engineer , ^ J Contractor Inspector's Nam Subcontractor TESTS PERFORMECr TYPE OF SAMPLE SLUMP' V , QUANTITY IN SET / AOOmONAL REMARKS ON SAMPLE INSPECTION"SUMMARY- LOCATfONS OF.<.WOHK 1(>JSff6CTe&.- TESTt"5AMPtEafT7>tKEN;L;WORKtBEJECTED, '30B^PR0BLEMSr*RR0<^ESS, REMARI<S. ET€( iNGHJOESJlNEORMATIOWABOgiL'--" AMOUN^FSf OF'MilVrERlAL RtTKGEEltOR-WDRIC'PERFDRMED, NUMBER.-TYRE &' IDENT "NO'SrOF TESTSAMP1:E5TAKEN STRUCTTCONNEGTIONSfWELDiWdElH^T-'BOLTS^-roROUEDrCHECKED, ETC" • \ • 777;. Js nn pro ^-^/J'WCr ' T 7 \ • CERTIFICATION OF COMPtlANCE' * * .V. '\ - •l-HEREBY CERTIFY THAT I HAVE OBSERVEP TOTHE-SEST^OF MY KNOWLEDGE. ALL OF THE ABOVE REPORTED WOJIK UNLESS OTHERWISE NOTED, I HAVE •FOUND THIS WORK TO COMPLY WITH THE APPROVED.PLANS.' SPECIFlpATlON ANO.AP^ICABLE SECTION OF THE GOVERNING BUILDING LAWS. • Vi,.' CONTINUED 0[* NptT PAGE Q PAGE OF s^: ANO.AP^ICABLE SECTION OF THE GOVERNING BUILDING r ^SSSNATUREOF REGISTERED lHS?fCTOR I SPECIALTY ' AGEN6Y . .\Nhit&'- Office Gopy •'Canary - Accounting-Copy • Pink - lnspector*s.Copy • Goldenmd- Jobsite Copy Southwest Inspection and Testing, inc. 441 Commercial: Way^ La Hat>ra, Ca 90631 (562) 94^-2990: •^(7^14$^^526-84^1 •^fax (562) '946-002& REGISTERED INSPECTOR'S DAILY REPORT TYPE OF INSPECTION REQUIREO 1 Reinforced Concrete v Post Tensioned Concrete Reinforced Masonry SWIT Job No Date • Structural Steel Assembly • Quality Control D Fire Proofing • Asphalt C] Wood Framing • Other Job Address Job Name Cit9 Type of Stru icture _ Matenal Descnption (type, grade, source) iXoe^5?'5^ ame Pemnit No. Architect Issued By Jiheer . _ / rt' —. " lontractor ^ . , ^ Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET-' . . ADDITIONAL REMARKS:ON.SAtMPLB INSPEGTION;SUMWARyi^"'LOCATlONS' 0F-WORK"4NSPEGTEDf"IEST -SAMPXES: TAKEN; WORK RE'JECTEO.T'JOff' PROBLEMS,' PROGRESS* RBWWRKS.:ETC-"INCLUDES-INFORMATJON ABOUT,.';^MOUNra,OF^TERIAfe'ptLAOED^ORlWOR(^fERE0RMEaT^UMBER:TYPE,^ OF -TBST'SAMPLES TAKEN' STRUCT CONNECTIONS' (WEUD MABE.HhH,BOEiTS TORQOED) eH'ECKED.:ETC" ' _ , J 1 -i-l ^? - t?-7,^ a a og//^5n20 -—^ ^ - ^ tl— ^ Trm. cin^ofi^T^ fTAc^ 3l<2 7c^ ^ ^CONTINUEPON'NEXT'PAGE ' PAGE' TIME OUT CERTIFICATION OF COMPLIANCE ' /;'*•' • t HEREBY CERTIFY THAT I HAVE OBSERVED TO THE BEST KVQWLEDffE^^:: ,ALL OP THE ABOVE^REPORfED W0RK>UNLESS'gTHERV9!SE'N0Tep,'-l'HAVE •" - FOUND THIS'WORK TO COMPLY WITH THE APPROVED PLANS, SPECIFiCAT10(4; ' f AN&APPLICABiE SECTIDN'OF THE GOVERNING BUILDING LAWS - ' - " - ' ^^^S^cSiry ^' ~ - • NO ' • AGENCY,- , ' White ~ Offlce^Copyi Canary-^ACcounhng Copy Pin/r^/nspector^Copy^^iGQ/denracf—JoOs/fe Copy^- SAMPLES- Approved By Project Superintendent' Southwest Inspection and Testing, Inc. I 441 Commercial Way, La Habra, Ca 90631 _ (562) 941-2990 • (714) 526-8441 • Fax (662) 946-0026 " REGISTERED INSPECTOR'S DAILY REPORT SWIT Job No Date TYPE OF INSPECTION REQUIRED • Reinforced Concrete Q Post Tensioned Concrete • Reinforced Masonry • Structural Steel Assembly • Fire Proofing • Asphalt • Quality Control • Wood Framing • Other Job Address Job Name Type of Structure _ Issued By Architect <it.O'.u tg^i^^ (^/}^ ^.1 ^O/^ I Matenal Descnption (type, grade, source) , Engineer 5\A^,F) h ^ :^c,\A/-r S S<y /Mrf<, Contractor ^/ ^ / Inspector's Name Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLE INSPECTION SUMMARY - LOCATIONS OF WORK INSPECTED, TEST SAMPLES TAKEN. WORK REJECTED. JOB PROBLEMS. 'PROGRESS, REMARKS, ETC INCLUDES INFORMATION ABOUT - AMOUNTS OF MATERIAL PLACED OR WORK PERFORMED. NUMBER TYPE & IDENT NO'S OF TEST SAMPLES TAKEN STRUCT CONNECTIONS (WELD MADE H T BOLTS TORQUED) CHECKED, ETC /9 7;u^.J /\yrJ. ,,^ry /^"w^ r TIL T I CERTIFICATION OF COMPLIANCE I HEREBY CERTIFY THAT I HAVE OBSERVED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED I HAVE FOUND THIS WORK TO COMPLY WITH THE APPROVED PLANS SPECIFICATION AND APPLICABLE SECTION OF THE GOVERNING BtJltOlNG LAWS CONTINUED ON NEXT PAGE • RAGE L OF J_ KBLf SE Ll IVERNING^ SIGNATURE OF REGISTERED INSPECTOR SPECIALTY NO AGENCY TIME IN TIME OUT SAMPLES Approved By ProJ«;t Superintendent White - Office Copy • Canary - Accounting Copy • Pink - Inspector's Copy • Goldenrod - Jobsite Copy vf Southwest Inspection and Testing, Inc. pA^'^ 441 Commercial Way, La Habra, Ca 90631 (562) 941-2990 • (714) 526-8441 • Fax (562) 946-0026 REGISTERED INSPECTOR'S ISAILY REPORT SWIT Job No Date TYPE OF INSPECTION REQUIRED Z] Beinforced Concrete ^ M'^Post Tensioned Concrete UJ Reinforced Masonry • Structural Steel Assembly Q Fire Proofing • Asphalt • Quality'Control • Wood Framing • Other Job Address \t _ ^ ^ City _ Job Name Permit No 10 S/ Issued By Type of Structure Architect / *--f IA Matenal Descnption (type, grade, source) Engineer Contractor Inspector s Name ft: A Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARjJS ON SAMPLE INSPECTION SUMMARY- LOCATIONS OF WORK INSPECTED, TEST SAMPLES TAKEN WORK REJECTED JOB PROBLEMS PROGRESS. REMARKS ETC INCLUDES INFORMATION ABOUT'-AMOUNTS OF MATERIAL'PLACED OR WORK PERFORMED, NUMBER TYPE & IDENT NOS OF TEST SAMPLES TAKEN STRUCT CONNECTIONS'lWELD MADE'H T BOLTS TORQUED) CHECKED, ETC ' - ^ l^-^^^ c c,:>e',o •.^r;r--^ , ,r^-3 ^ A. -/7 /c? r.A /^C^^>A •if 4-^ 7 7^„ CERTIFICATION OF COMPLIANCE 1 HEREBV CERTIFY THAT I HAVE OBSERVED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE,NOTED I HAVE FOUND THIS WORK TO COMPLpWffRSffiE APPROVED^ANS (SPECIFICATION AND APPLICABLE SECTlON-tJFJHE GOVEfiNING BUlUeifl^AWS CONTINUED ON NEXT PAGE Q PAGE OF SPECIALTY NO ( AGENCY TIME IN TIME OUT SAMPLES Ir . -t ^ — • Approved By " ^^^7>^ Project's uperintfendent White - Office Copy • Canary - Accounting Copy • Pink - Inspector's Copy • Goldenrod - Jobsite Copy / Southwest Inspection and Testing, Inc. 441 Commercial Way, La Habra, Ca 90631 (562) 941-2990 • (714) 526-8441 • Fax (562) 946-0026 REGISTERED INSPECTOR'S DAILY REPORT SWIT Job No TYPE OF INSPECTION REQUIRED D Reinforced Concrete D Post Tensioned Concrete • Reinforced Masonry Q Stmctural Steel Assembly D Fire Proofing • Asphalt n Quality Ofentrol O Wood Framing • Other Job Address City Permit No Issued By Type of Structure Architect Material Description (type, grade, source) Engineer Contractor Inspector's Name -f^ f ^/r H- A' , Subcontractor TESTS PERFORMED TYPE OF SAMPLE SLUMP QUANTITY IN SET ADDITIONAL REMARKS ON SAMPLE INSPECTION SUMMARY- LOCATIONS OF WORK INSPECTED TEST SAMPLES TAKEN WORK REJECTED, JOB-PROBITEMS. PROGRESS, REMARKS ETC INCLUDES INFORMATION ABOUT - AMOUNTS OF MATERIAL PLACED ©R WORK PERFORMED NUMBER TYPE & IDENT NO'S OF TEST SAMPLES TAKEN STRUCT CONNECTIONS (WELD MADE H T BOLTS TORQUED) CHECKED, ETC { -17(^ 1779, • /- J 1 -7^.Z • /•^ ^-' t ^1 C-r^^' r 7 1 -1 y'-zc CERTIFICATION OF COMPUANCE I HEREBY CERTIFY THAT I HAVE OBSERVED TO THE BEST OF MY KNOWLEDGE ALL OF THE ABOVE REPORTED WORK UNLESS OTHERWISE NOTED I HAVE FOUND THIS WORK T0p3MFlTWlTHTtife APPROVED PL^W? SPECtnCATION AND APPLICABLE SSCSpN OF TMPffti^RNING BUIL CONTINUED ON NEXT PAGE • PAGE SPECIALTY AGENCY TIME IN TIME OUT SAMPLES Approved BV ' Project Superintendent White - Office Copy • Canary ~ Accounting Copy • Pink - inspector's Copy • Goldenrod - Jobsite Copy