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CITY OFADMOINDS --- EN(;1,`NiEERFNG DIVISION,,
SPEC,"IAI, INSPETTION� ANDIIESTINGC, 11EEN,
DATE.
PROJECI'S ITT AD DRESS
PIU)JEcTr
SPECIAL INSPECTIO:
N AGENCY
*Onc form mu,,4 be compkted by n. t2 ell m fns
SPECIAL INSPECTIONS REQ1 IRED; Spocial inspections reqUi"cd Rg thl pnjecL as
"'111 'r':tle '� [`dnlolads COrlmlwig DooWpawnt We ([CDC, j!,jt
the r,�gL,Iered d,-sjiqn proly, h, v"in21witI)lvCdfii,1r1mWmsmhuacllkejmPMaroyananwoWNeeu plawIand hrgecificadow Nco"wrorraWsNWtinlispection
ageng-special
inspLcm it to pet Wo ly"al smial impuctims. The Nxecial in, mur :,l d! by a quWANd loc"mi n 41.1
compatenca Wr Wyewing the 1, P,:, of construction or operation requiring special inspection.
ov-net. mgi, tercd pl'olession'-fl. cullif Ictor and ,spec hl SNIII pro\ idc to speci'd insp.,ctiolc
report (ktailing 41`1t1—jp',)r0% I)ILM',Md SWINadops direct,i to tll(., 1,
Dk isiojj.
V�
OR K RE'QURING NPF'CIAI, f \spl,,c,, nC , SPAY KFJCLA011, k, ill kc requir,d 1"or the 1'ollk)�N ins,,
cawgodes of vvk: FOR SPEC HIC INPURAFAI10N R1-'GARI-)[NCi I�F,QUFRED
IN�N','("HON'S SEE ITIE 9FAKWUN F 0F SETCLIL KSVL(, F10N N01 -1 -D .',S A (.'0NDI'I 10'%;
THE BI JLDING PERNIF f W -)UR UN 211E APPROVED Pf ON,
EJ Fps skynow puzmew zd cmn,,d,jj
PerN ions 11op i,,L1,- ta, , i ,
Ins llal ('11
Erosion and SeTmInt Control and SWpv my,. dor,
ArnotUAWkin
Final 100
BEFORE A IAV V177 CvC ISE:: j,"St ED: IN twna ak canUmtor and spmhd ingwor sQ11
MITI, to thi, -,,,r,�wnwnt urld WWII to a I'Amnit Coordinator 10ur u) por-th LAuatwc,
APPROVAL �.1�
SPECULIPCTURLocspiinspector SI -Al be appmxcd by tiin;isionprto perimAndmic, or ir Too hms, Thocredonkrisofthesedhermon
pwAmOng Me nywA AM ba suNnitted- Kim jp1dicame, the corn,,.act s Alton.
must NO amedived b3,�
WASH11)) III & Tv AmericAn Awsodation of We Fhghwy and TwnTonakm (A6djI,,
A, Duties and, Resp-Qnsibi)cies of thel
S- 'a
P—ee-
1, OBSERVE WORK
The special inspector shall observe the site work for coofol-mance with the approvcd (staniptch
Plans and specifications. Special inspections are to be per as needed, lo confirm that the
Nvorl� being Completed Meets specifications and approved plans,
2. RE PORT NONCONFORIWING ITEMS
The special inspector shall brim, non-conforr-nino iterns m
r' Zto the 'rnediate attention of the
contractor and engineer of record. The special inspector shall pro -vide a report to the Engineering
Division nofifj�ing of any literns not resolved and/or not installed per the approved plans and
specifications,
Items not constructed per the approved plan Ls and Specifications -will result in a review of ffie plans
to detem-Tinc -what I
reqLrircments will be needed for the project to Ineet the necessary storn"I""ater
requirements; such as removal and reconstruction, re'
I -desig- of the storniwater management
system(s), etc.
Final approval for the project will not occur until Installation of required improvnir ents
p I I is
con-lPlete and accepted by the Special Inspectorand tljF- Cit -y,
3, FINAL CONSTRUCTIOIN REPORT
The special inspector or inspection agency shall subrn4 a final signed report or Ce IN ate 0
Compliance to the City Stalin,- that all Items requin-111- special inst"'ection and testing Nvere fulfilled
and reported, The rcpOT1 shall also include a staiterrierit froin 'the inspector stating to tji- best of
his/her kno,vOedge the project is in conformance Avith the appro� -, 1 pla,
os7
approved platirevisions, if any. Items not in conformance, unresolved items or any discrcpa I ncits
11i inspection coverage (i.e., Missed inspections, periodic inspection rvheri contirtuous fiTspectiouS
wercrequirecl. O'Lc,) shall be specit-ically addressed in this report.
B. ons actor' Res onsibilifies
�� �IUC4 �1111' -
L NOTJFY THE SPECIAL INTSPECTOR OF ALL REQUIRED SPECIAL INSME-C-7FIONS
h is the out), of the contractor to rectify,
the special inspector w
OTC- TOT, special
n w 0rk i s ready
inspection- Note, the items listed under the statement ofspec;
amend as noted on ,he approved1-31 inspection On the building pej-jrit
a
plans and specifications are requirtcl ispecial e
-o tieve �,�pe il sp cho 1,S
Adec]Utc notice shall be provided by the contractor so that the special inspector has tirne to
becomc familiar with the project. All work requiring special inspection must be appro,,,cd pj-io, to
concealing or covering said work,
2, PROVIDE ACCESS TO AP13ROVED PLANS
'I he contractor is responsible for providing the special inspectoi, a%.C'eSs t0 approved plans r:? e
Jobsite.
'IN SPLECIAL INSPECTION RECORDS
1UTA1
1 h= contractor JS responsible to retain at the lob site all special inspection records stib-n-litted by thle
special inspector, hese records are to be provided to the Cit -v 1,', I c) upon req Lt Ji
and ulpoii conipletion of Lvori�, I
C ��Edmonffls -'.fit-wee 2 Division R
ties
1, APPROVE SIPEC IAL INSPECTION
-I FTi,nt-prino YY PIT
W(arl~ rquiling 'Ixckl Wspectiml and rwrRnmance of spedal K"IMS §YH be numhomd by Vc
lingineering Mision hispWor, EfR, jflee6tT Inspector kq)proN ad Mut be obMWed Qvio
placcnwnt of concnic or othei shnior acq1ties hi addi6on to that of the special inspeclol,
I PINAL
.a is
'i iRDivision nrj��y ptj)vide final inspectiorl appr()V11 atier the spe(,-jjjl
repufl(s) have been subtnim(1 Mid ac ccpted by dic.^ C'hy
Owliel', Respp'qT jy
1. 1 he jr0ect o"nor or the engineer or architect of rccurd acj�o)g �)S the:rear j
special inspection SOIN iccs.
11tie
L 10M SWornent, of'Spec,,-
,11
lbwiew the special inspection reports and proWe c0nective action 6or \Nor,J� tj,,ajt n0(
1-0 1hc approvcd plans
I have iwad and (qnw? to ('60VIT-With the ferans- and condition.a of thi's agreelnelm
ol,v n C Ir a:Ia In C
wy P0. rar dapaaa--- --- ..........n.. „,. ... ..
Tgnature . ......
Date—
Geneml Qnh-actoi� ""I/ , , -�! (
........ . . : (' "' , " "
' wk3wQ7 .01
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SPecial filspector/Agency name
Synahwe
Engineer of Record nomp
Sig"nature
(p I fa �Lp—Hn No
Return the orighmi sl ned RgmCment W.,
0I of Edmowls DO'ClOP'nerit Services Department
121 5"' Avenue Plooh, My HWJ Secoud Flow-
Edma"dq NV A 9MU0
i "M (QUAT-00
Date
MWEIMEJ) ou, r!�
pp
CIO OMNI Swnwre
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