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Appendix A Blank Forms

Page 1 of 3

CATAWBA COUNTY, NORTH CAROLINA SPECIAL INSPECTIONS PROGRAM Statement of Special Inspections

TPI Permit #1:

TPI Permit #2:

TPI Permit #3

________________

________________

___________________________

(TPI Permit Numbers to be furnished by CCBSD)

____________________________________________________

________________________

______________________________________________________

Occupancy:__________

_________________

_____________________________________________________

Construction Type:___________________

PROJECT:

Address:

NCSBC Edition:

Building Owner:

__________________________________________________________________________________ Name Company

Owner's Address:

_________________________________________________________________________________

Architect of Record:

_______________________________________________________________________________

Name & License

Company

Structural Engineer of Record:

______________________________________________________________________

Name & License

Company

Geotechnical Engineer of Record:

___________________________________________________________________

Name & License

Company

Special Inspections Engineer of Record 1 :

___________________________________________________________

Name & License

Company

Special Inspections Engineer of Record 2:

____________________________________________________________

Name & License

Company

Special Inspections Engineer of Record 3:

____________________________________________________________

Name & License

Company

General Contractor:

_______________________________________________________________________________

Name & License

Company

This Statement of Special Inspections is submitted as a condition for permit issuance in accordance with the North Carolina Statewide Building Code. It includes a schedule of special inspections applicable to this project.

The Special Inspections Engineer of Record shall keep records of specified special inspections and testing and shall furnish copies of inspection and testing reports to the Catawba County Building Services Division and to the appropriate registered design professionals of record. Discrepancies from the approved plans and specifications and code violations observed during the conduct of special inspections services shall be brought to the immediate attention of the contractor for correction, to the attention of the Catawba County Building Services Division, and to the appropriate registered design professionals of record. A final report of special inspections documenting completion of specified special inspections and correction of any discrepancies and observed code violations noted in the inspection and testing reports shall be submitted to the Catawba County Building Services Division prior to the request for final building inspection and building inspection approval by County staff.

Prepared by Registered Design Professional in Responsible Charge:

_______________________________________________________ (Type or print) Name

_______________________________________________________________ Signature & Date

Building Owner's Authorization:

__________________________________________________

Signature & Date

Building Official's Acceptance:

_____________________________________________________

Catawba County Building Services

Signature & Date

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