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- Special Inspection Form Rev. - 12-30-08 (City of Gonzales)

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STATEMENT OF SPECIAL INSPECTIONS
SITE
ADDRESS
APN BP#
Owner............................................................................................................
Address .........................................................................................................
Cit
y
/St..................................................Zi
p
..............
Phone
...........................
Contractor ........
.............................................................................................
Address .........................................................................................................
Cit
y
/
St............................................... Zi
p
..................
Phone
.........................
Petitioner
.......................................................................................................
Address .........................................................................................................
City/St.................................................Zip ..............
Phone
...........................
Engineer/Architect
.........................................................................................
Address .........................................................................................................
City/St............................................... Zip
..................
Phone
.........................
PROJECT DESCRIPTION:
This “STATEMENT OF SPECIAL INSPECTIONS” is submitted in fulfillment of the requirements of CBC Sections 1704 and 1705. This
form is structured after and used by permission from the Structural Engineers Association of Northern California’s
(SEAONC) model
statement of Special Inspections. Also included shall be the following:
“LIST OF TESTING AGENCIES” (page 2). A list of the testing agencies and other special inspectors that will be retained to
conduct the tests and inspections for this project.
“SCHEDULE OF SPECIAL INSPECTION” (page 3 - 6). The Schedule of Special Inspections summarizes the Special
Inspections and tests required. Special Inspectors will refer to the approved plans and specifications for detailed special
inspection requirements. Any additional tests and inspections required by the approved plans and specifications will also be
performed.
Special Inspections and Testing will be performed in accordance with the approved plans and specifications, this statement and CBC
sections 1704, 1705, 1707, and 1708. Interim reports will be submitted to the Director of Building Services and the Registered Design
Professional in Responsible Charge in accordance with CBC Section 1704.1.2
A Final Report of Special Inspections documenting required Special Inspections, testing and correction of any discrepancies noted in
the inspections shall be submitted prior to issuance of a Certificate of Use and Occupancy (Section 1704.1.2). The Final Report will
document:
Required special inspections.
Correction of discrepancies noted in inspections.
The Owner recognizes his or her obligation to ensure that the construction complies with the approved permit documents and to
implement this program of special inspections. In partial fulfillment of these obligations, the Owner will retain and directly pay for the
Special Inspections as required in CBC Section 1704.1.
This plan has been developed with the understanding that the Director of Building Services will:
Review and approve the qualifications of the Special Inspectors who will perform the inspections.
Monitor special inspection activities on the job site to assure that the Special Inspectors are qualified and are performing their
duties as called for in this Statement of Special Inspection.
Review submitted inspection reports.
Perform inspections as required by the local building code.
I have read and agree to comply with the terms and conditions of this statement
1 of 7
Prepared By:
Project Engineer Architect:
Registered Desig
n Professional in Charge
Signature:
.....................................................................
Lic. #:
....................................Date:
.............................
Owner Name:
Owner’s Authorization Signature:
....................................................................................................................Date:
.............................
Inspection Agency / Inspector Name:
Signature:
....................................................................................................................Date:
.............................
Building Official:
Building Official’s Acceptance
Signature:
....................................................................................................................Date:
.............................
City of Gonzales
Building Department
P.O. Box 647 147 Fourth Street Gonzales, CA 93926
Phone: (831) 675-5000 Fax: (831) 675-2644 www.ci.gonzales.ca.us
1 0f 7
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LIST OF SPECIAL INSPECTION AGENCIES
APPROVAL OF SPECIAL INSPECTORS:
Each special inspection agency, testing facility, and special inspector shall be recognized by the Director of Building prior to performing
any duties. Special Inspection agency’s listed on this form must be pre-approved and listed on Monterey County’s approved Special
Inspector’s list. Special inspectors shall carry approved identification when performing the functions of a special inspector and call the
Building Services Department each day the special inspection is performed. Identification cards shall follow the criteria set by the
California Council of Testing and Inspection Agencies
. No personnel changes shall be made without first obtaining the approval of the
Building Official. Any unauthorized personnel changes may result in a “Stop Work Order” and possible permit revocation. To be pre-
approved by Monterey County, a company profile including resumes of all employees, their certifications and a list of the types of work
for which recognition is requested shall be submitted to the Director of Building for review. The initial processing fee is $300 per agency
with an annual renewal fee of $100. Please allow two weeks to complete the application process.
The following are the testing and special inspection agencies that will be retained to conduct tests and inspection on this project:
EXPERTISE FIRM / INSPECTOR INFORMATION
*
1. Special Inspection (except for
geotechnical)
Firm
...........................................................................Addr
.................................................................................................
City
............................................................................................................................
State ...................Zip ......................
Tele
p
hone
............................................ Fax.............................................. Email
...............................................................
2. Material Testing
Firm
...........................................................................Addr
.................................................................................................
City
............................................................................................................................
State ...................Zip ......................
Telephone
............................................ Fax..............................................
Email
...............................................................
3. Geotechnical Inspections
Firm
...........................................................................Addr
.................................................................................................
City
............................................................................................................................
State
....................Zip
..................
Telephone
.............................................Fax .............................................
Email
...............................................................
4. Other:
Firm
...........................................................................Addr
................................................................................................
City
............................................................................................................................
State ...................Zip .....................
Telephone
.....................................
Fax ..............................................
Email
...............................................................
*All agencies specified on this form must be pre-approved and listed on Monterey County’s Approved Special Inspector’s List.
SEISMIC REQUIREMENTS (Section 1705.3.1)
Description of seismic-force-resisting system and designated seismic systems subject to special inspections as per Section 1705.3:
The extent of the seismic-force-resisting system is defined in more detail in the construction documents.
WIND REQUIREMENTS (Section 1705.4.1)
Description of main wind-force-resisting system and designated wind resisting components subject to special inspections in accordance with Section
1705.4.2:
The extent of the main wind-force-resisting system and wind resisting components is defined in more detail in the construction documents.
2 of 7
SCHEDULE OF SPECIAL INSPECTION
SITE
ADDRESS
APN BP#
PROJECT DESCRIPTION:
Notation Used in Table:
Column headers:
C Indicates continuous inspection is required.
P Indicates periodic inspections are required. The notes and or contract documents should clarify.
Box entries:
X Is placed in the appropriate column to denote either “C” continuous or “P” periodic inspections.
--- Denotes an activity that is either a one-time activity or one whose frequency is defined in some other manner.
Additional detail regarding inspections and tests are provided in the project specifications or notes on the drawings.
Code Section Verification and Inspection
C P NOTES
1704 – SPECIAL
INSPECTIONS
1704.2.1
□ Inspect fabricator’s fabrication and quality control
procedures.
--- ---
1. Material verification of high-strength bolts, nuts, and washers.
X
□ Identification markings to conform to ASTM stds
specified in the approved construction documents.
□ Manufacturer’s certificate of compliance required.
X
2. Inspection of high-strength bolting:
X
□ Bearing-type connections.
□
Slip-critical connections
X X
3. Material verification of structural steel:
--- ---
□ Identification markings to conform to ASTM stds
specified in the approved construction documents.
□ Manufacturer’s mill test reports
--- ---
4. Material verification of weld filler materials:
--- ---
□ Identification markings to conform to AWS
designation listed in the WPS.
□ Manufacturer’s certificate of compliance required.
--- ---
5. Inspection of welding for Structural steel
X
X
X
X
□ Complete and partial penetration groove welds.
□ Multipass fillet welds.
□
Single-pass fillet welds > 5/16”
□ Single-pass fillet welds ≤ 5/16”
□ Floor and roof deck welds.
X
6. Inspection of welding for Reinforcing steel
X
X
X
□ Verification of weldability of reinforcing steel other
than ASTM A706.
□ Reinforcing steel-resisting flexural and axial forces in
intermediate and special moment frames, and
boundary elements of special reinforced concrete
shear walls, and shear reinforcement.
□
Shear reinforcement.
□
Other reinforcing steel
X
7. Inspection of steel frame joint details for compliance with approved construction documents:
Table
1704.3
STEEL
a. Details such as bracing and stiffening.
b. Member locations.
c. Application of joint details at each connection.
X
X
X
1704.3
WELDING
1. □
Welded studs when used for structural diaphragms.
2.
□ Welding of cold-formed sheet steel framing
members.
3.
□
Welding of stairs and railing systems.
X
3 of 7
Code Section
Verification and Inspection
C P NOTES
1. □ Inspection of reinforcing steel, including prestressing
tendons and placement.
X
2. □ Inspection of reinforcing steel welding in accordance
with Table 1704.3 Item 5b.
--- ---
3. □ Inspect bolts to be installed in concrete prior to and
during placement of concrete where allowable
loads have been increased.
X
4. □ Verifying use of required design mix.
X
5. □ At time fresh concrete is sampled to fabricate
specimens for strength tests, perform slump and air
content tests and determine the temperature of the
concrete.
X
6. □ Inspection of concrete and shotcrete placement for
proper application techniques.
X
7. □ Inspection for maintenance of specified curing
temperature and techniques.
X
8. Inspection of prestressed concrete
X
□ Application of prestressing forces.
□
Grouting of bonded prestressing tendons in the
seismic force-resisting system.
X
9. □ Erection of precast concrete members.
X
10. □ Verification of in-situ concrete strength, prior to
stressing of tendons in postensioned concrete and
prior to removal of shores and forms from beams
and structural slabs.
X
1704.4
CONCRETE
11. □ Inspect formwork for shape, location, and
dimensions of the concrete member being formed.
X
1. At the start of masonry construction verify the following to ensure compliance:
□ Proportions of site-prepared mortar.
X
□ Construction of mortar joints.
X
□ Location of reinforcement, connectors, prestressing
tendons, and anchorages.
X
□ Prestressing technique.
X
□ Grade and size of prestressing tendons and
anchorages.
X
2. Verify:
X
X
X
X
X
□ Size and location of structural elements.
□
Type, size, and location of anchors, including other
details of anchorage of masonry to structural
members, frames or other construction.
□
Specified size, grade, and type of reinforcement.
□
Welding of reinforcing bars.
□ Protection of masonry during cold weather
(temperature below 40 degrees F) or hot weather
(temperature above 90 degrees F)
□ Application and measurement of prestressing force.
X
3. Prior to grouting verify the following to verify compliance.
X
X
X
□ Grout space is clean.
□ Placement of reinforcement and connectors and
prestressing tendons and anchorages.
□ Proportions of site-prepared grout and prestressing
grout for bonded tendons.
□
Construction of mortar joints.
X
4. Grouting
X
Table
1704.5.1
LEVEL
1
MASONRY
INSPECTIONS
□ Verify grout placement to ensure compliance with
code and construction document provisions.
□ Observe grouting of prestressing bonded tendons.
X
4 of 7
Code Section
Verification and Inspection
C P NOTES
5. □ Observe preparation of required grout specimens,
mortar specimens, and/or prisms.
X
6. □ Verify compliance with required inspection provisions
of the construction documents and the approved
submittals.
X
1. From the beginning of masonry construction the following shall be verified to ensure compliance:
X
X
X
X
X
Table
1704.5.3
LEVEL
2
MASONRY
INSPECTIONS
□ Proportions of site-prepared mortar, grout, and
prestressing grout for bonded tendons.
□ Placement of masonry units and construction of
mortar joints.
□ Placement of reinforcement, connectors and
prestressing tendons and anchorages.
□ Grout space prior to grouting.
□
Placement of grout.
□
Placement of prestressing grout.
X
2. Verify
X
X
X
X
X
□ Size and location of structural elements.
□ Type, size, and location of anchors, including other
details of anchorage of masonry to structural
members, frames and other construction.
□ Specified size, grade, and type of reinforcement.
□
Welding of reinforcing bars.
□
Protection of masonry during cold weather
(temperature below 40 degrees F) or hot weather
(temperature above 90 degrees F).
□ Application and measurement of prestressing force.
X
3. □ Preparation of any required grout specimens,
mortar
specimens, and/or prisms shall be
observed.
X
Table
1704.5.3
LEVEL
2
MASONRY
INSPECTIONS
4. □ Compliance with required provisions of construction
documents and the approved submittals shall be
verified.
X
1. □ Inspect prefabricated wood structural elements and
assemblies in accordance with Section 1704.2
--- ---
1704.6
2. □ Inspect site built assemblies.
---
1. □ Verify grade and thickness of sheathing.
---
2. □ Verify nominal size of framing members at adjoining
panel edges.
---
3. □ Verify:
1704.6.1
HIGH-LOAD
DIAPHRAGMS
a. Nail or staple diameter and length,
b. Number of fastener lines,
c. Spacing between fasteners in each line and at
edge mar
gins.
---
---
1. □ Verify materials below footings are adequate
to
achieve the desired bearing
capacity.
X
2. □ Verify excavations are extended to proper depth and
have reached proper material.
X
3. □
Perform classification and testing of controlled fill
materials.
X
4. □ Verify use of proper materials, densities and lift
thicknesses during placement and compaction of
controlled fill.
X
Table
1704.7
SOILS
5. □
Prior to placement of controlled fill, observe subgrade
and verify that site has been prepared properly.
X
1. □
Verify pile materials, sizes and lengths comply with
the requirements.
X
2. □ Determine capacities of test piles and conduct
additional load tests, as required.
X
Table
1704.8
PILE
FOUNDATIONS
3. □ Observe driving operations and maintain complete
and accurate records for each pile.
X
5 of 7
Code Section Verification and Inspection
C P NOTES
4. □ Verify locations of piles and their plumbness.
a. Confirm type and size of hammer.
b. Record number of blows per foot of penetration.
c. Determine required penetrations to achieve design
capacity.
d. Record tip and but elevations and record any pile
damage.
X
5. □ For steel piles, perform additional inspections in
accordance with Section 1704.3.
--- ---
6. □ For specialty piles, perform additional inspections as
determined by the registered design professional in
responsible charge.
--- ---
Table
1704.8
PILE
FOUNDATIONS
7. □ For augered uncased piles and caisson piles,
perform inspections in accordance with Section
1704.9.
---
---
1. □ Observe drilling operations and maintain complete
and accurate records for each pier.
X
2. □ Verify locations of piers and their plumbness. Confirm:
Table
1704.9
PIER
FOUNDATIONS
a. Pier diameters,
b. Bell diameters (if applicable),
c. Lengths, embedment into bedrock (if applicable),
d. Adequate end st
r
ata bearin
g
capacit
y
.
X
--- ---
--- ---
X
--- ---
--- ---
1704.10
SPRAYED
FIRE-
RESISTANT
MATERIAL
1. □ Inspect surface for accordance with the approved
fire-resistance design and the approved
manufacturer’s written instructions.
2.
□ Verify minimum ambient temperature before and
after application.
3.
□ Verify ventilation of area during and after application.
4. □ Measure average thickness per ASTM E605 and
Section 1704.10.3.
5.
□ Verify density of material for conformance with the
approved fire-resistant design and ASTM E605.
6.
□ Test cohesive/adhesive bond strength per Section
1704.10.5.
--- ---
1704.11
□ Mastic and Intumescent Fire-Resistant Coating
--- ---
1704.12
□ Exterior Insulation and Finish Systems (EIFS)
---
---
1704.13
□ Alternate Materials and Systems
--- ---
1704.14
□ Smoke Control System
--- ---
SECTION 1705 – STATEMENT OF SPECIAL INSPECTIONS
1705.3.4
[4.3]
SEISMIC
□
Suspended ceiling systems and their anchorage.
--- ---
--- ---
--- ---
--- ---
--- ---
--- ---
1705.4.2
WIND
1. □ Roof cladding and roof framing connections.
2.
□ Wall connections to roof and floor diaphragms and
framing.
3.
□ Roof and floor diaphragm systems, including
collectors, drag struts and boundary elements
4.
□
Vertical wind-force-resisting systems, including
braced frames, moment frames, and shear walls.
5.
□
Wind-force-resisting system connections to the
foundation.
6.
□ Fabrication and installation of systems or
components required to meet the impact resistance
requirements of Section 1609.1.2.
--- ---
6 of 7
Code Section Verification and Inspection
C P NOTES
SECTION 1707 - SPECIAL INSPECTION FOR SEISMIC RESISTANCE
1707.2
□ Special inspection for welding in accordance with
AISC 341.
X
□ Inspect field gluing operations of elements of the
seismic-force-resisting system.
X
1707.3
WOOD
□ Inspect nailing, bolting, anchoring, and other
fastening of components within the seismic-force-
resisting system, including:
a. wood shear walls, b. wood diaphragms, c. drag
struts, braces, d. shear panels, e. hold-downs.
X
X
1707.4
COLD-FORMED
STEEL
FRAMING
□
Welding of elements of the seismic-force-resisting
system.
□ Inspection of screw attachments, bolting, anchoring,
and other fastening of components within the
seismic-force-resisting system including struts,
braces, and hold-downs.
X
X
1707.5
PIER
FOUNDATIONS
1. □ Placement of reinforcing
2.
□ Placement of concrete
X
1707.6
□ Anchorage of storage racks and access floors 8 feet
or greater in height.
X
X
X
1707.7
ARCHITECTURAL
COMPONENTS
1. □ Inspect erection and fastening of exterior cladding
weighing more than 5 psf.
2.
□ Inspect erection and fastening of interior and exterior
non-bearing walls weighing more than 15 psf.
3.
□ Inspect erection and fastening of interior and exterior
veneer weighing more than 5 psf.
X
X
X
X
X
1707.8
MECHANICAL
AND
ELECTRICAL
COMPONENTS
1. □ Inspect anchorage of electrical equipment for
emergency or stand-by power systems.
2.
□ Inspect anchorage of non-emergency electrical
equipment.
3.
□ Inspect installation of piping systems and associated
mechanical units carrying flammable, combustible,
or highly toxic contents.
4.
□
Inspect installation of HVAC ductwork that contains
hazardous materials.
5.
□
Inspect installation of vibration isolation systems
where required by Section 1707.8.
X
1707.9
□ Verify that the equipment label and anchorage or
mounting conforms to the certificate of compliance
when mechanical and electrical equipment must be
seismically qualified.
--- ---
1707.10
□ Seismic isolation system: Inspection of olation is
system per ASCE 7 – Section 17.2.4.8
X
SECTION 1708.1 - STRUCTURAL MASONRY TESTING FOR SEISMIC RESISTANCE
1708.1.1
□
Verify certificates of compliance prior to construction.
--- ---
1708.1.2
□
Verification of f’
m
and f’
AAC
prior to construction.
--- ---
1708.1.4
□
Verification of f’
m
and f’
AAC
every 5000 square feet
during construction.
X
1708.1.4
□
Verification of proportions of m terials in mortar and a
grout as delivered to the site.
--- ---
1708.3
□ Obtain mill certificates for reinforcing steel, verify
compliance with approved construction documents,
and verify steel supplied corresponds to certificate.
--- ---
1708.4
□
Structural Steel: Invoke the AP Quality AssuranceQ
requirements in AISC 341.
--- ---
1708.5
□ Obtain certificate that equipment has been tested per
Section 1708.5.
--- ---
1708.6
□
Obtain ystem tests as required by ASCE 7 Section s
17.8.
--- ---
7 of 7
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Completed 20 July 2020

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