LAKE HAVASU CITY
CERTIFICATE OF SPECIAL INSPECTION
Return completed certificate to the Community Investment Department
2330 McCulloch Blvd. N., Lake Havasu City, AZ 86403
Phone: 928.453.4148 Website: www.lhcaz.gov
PROJECT NAME: ____________________________________________________ DATE: _______________
PROJECT ADDRESS: ________________________________________________ PERMIT NO. __________
OWNER’S NOTIFICATION OF SPECIAL INSPECTION
To be completed and signed by Owner before a building permit is issued.
In accordance with Sections 1704 & 1705 of the International Building Code, which require that certain construction
work be placed under the inspection of a registered design professional, I, as owner/legal agent, do hereby certify that I
retained ____________________________________________ to be responsible for the special inspection.
(registered design professional/firm) – please print
Owner’s Name: ________________________ Owner’s Signature: _______________________________ Date: _________
CERTIFICATE OF RESPONSIBILITY
To be completed and signed by the professional in charge of special
inspections before a building permit is issued.
CERTIFICATE OF COMPLIANCE
To be signed by the professional in charge of special inspections
before a certificate of occupancy is issued.
As a registered design professional
in charge of special inspections of
the above named project. I certify
that I am familiar with the design
of the project and hereby assume
full responsibility for carrying out
the required special inspections in
accordance with Sections 1704 & 1705
of the International Building Code.
Seal, Signature & Date
I certify that, to the best of my
knowledge, the requirements
of the Building Code and the
approved plans and specifications
have been complied with, insofar
as the portion of the work requiring
special inspection under Section
1704 & 1705 is concerned, except
for those deviations previously
reported. A guarantee that the Seal, Signature & Date
contractor necessarily constructed
the building in full accordance with
the plans and specifications is neither
intended or implied.
Certificate of Special Inspection Page 1 of 2 04/15/2016
