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CITY OF TRACY DEVELOPMENT SERVICES DEPARTMENT TRACY BUILDINP;SAFETY DIVISION 333 CIVIC CENTER PLAZA, TRACY, CA 95376 P: (209) 831-6400 • F. (209) 831-6439 www.citvoftracy.org SPECIAL INSPECTION AGREEMENT FORM Prior to issuance of a permit Parts i throggh IV of this form shall be completed,signed,and submitted to the Building Official for review and.approve!. Part I shall be completed by the Owner or Owner's Authorized Agent. Part 11 shall be signed by applicable parties. Pert 111 shall be completed by the registered design professional(RDP)in responsible charge or the RDP responsible for structural design.Partly shall be completed by the General Contractor.Part V shall be completed by the Special Inspection Agency and submitted to the Building Official prior to final inspection or issuance of Certifica to of Occupancy.Please note that failure to comply with special inspection requirements may lead to additional project expenses and project delays due to issuance of stop work orders,destructive inspections &testing,in-situ load testing,and possible redesign. PART 1—PROJECT & INSPECTION AGENCY INFORMATION Joh:Names.l'?y_ '^Odes Address: Oso Eosi t tah street.Tray.CA 95376 Permit Number: CITYAPPROVED TESTING/INSPECTION AGENCY OR LABORATORY J7Z- 27-00 9, Y„ �ITQNXI��CU�i ETES ihG Phone Number: 209— Email Address: 11�H4i.LrV BA KI Agency 2: Phone Number: • CG✓r�► Email Address: A f�r of>7re at,aroved pecial inspection agencies lnav be obtainsd from the Building�j& 'vii n Link to Approved Agencies:httos.,IAvww.cityoftracy.or-p/?navid=1095f� ,ir.!t:;r'b.bmiG1Q'�.;'tt:”:;W,,•,ryiPra:• PART Il - SPECIAL INSPECTION AND TESTING AGREEMENT When special Inspections are required by Chapter 17 of the California Building Code(CSC),the RDA in responsible charge and RDP responsible for structural design shall prepare an inspection program (Part 111), which shall be submitted to the Building Official for approval prior to issuance of the building permit. The special inspector shall be employed by the owner or an authorized agent of the owner, BUT NOT the contractor, or any other person responsible for the work. The special inspection firms) named above haslhave) been authorized to perform the special inspection and testing services designated in this agreement, and in accordance with the CSC requirements, shall report all activities and results to the Building Official,and other parties as listed. It is understood that special inspections aret�ti',redin addition to,and are nota substitute for,the normal inspections performed by die Building Inspector. T14tin der fkned Werdby affirm,under penalty of law that the special inspection program is In accordance with the 06- -ff3ie CBC and the City of Tracy. The undersigned has used all reasonable diligence in completing this form'and to the best of his/her knowledge, the information contained herein is true and complete. The t ii dersigned hereby certifies under the penalty of perjury under the laws of the State of California that the foregoing Wove and correct. This plan has been developed with the understanding that the Building Official will: „ ?:Review and approve the qualifications of the Special Inspection Agency who will be responsible for the special Inspections required for the project. •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. Pg 1-•Revlied 11410812020 WASL iidinglSPECIAL INSPECTIOWSpecial Inspection Agreement Form_ Revised 4_2020.docx :i1Li«t