APPROVED SI FORM (SIGNED)OF >rD yo`ySPECIAL INSPECTION AND TESTING AGREEMENT
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Est. 1890
Permit M BLD2021-1418
Project: 17504 72nd Ave W
Prior to issuance of a permit, this form must be completed in its entirety and returned to the City for
approval. The completed form must have signatures of acknowledgment by all parties.
DUTIES AND RESPONSIBILITIES
Special Inspection Firm and Special Inspectors:
The Special Inspection firm of y f 6E)05G /LC
�. � Lt, t ��'�'`-CPS t�
will perform special inspection for the following types of work (separate forms must be submitted if more than one
firm is to be employed):
_Reinforced Concrete
_Bolting in Concrete
_Prestressed Concrete
Shotcrete
_Structural Masonry
Structural Steel/Welding
_High Strength Bolting
_Spray applied Fireproofing
_Smoke Control Systems
^Lateral Wood
X Soils
X Earthwork and grading activities monitored by the
Geotech engineer as described in the Geo report.
All individual inspectors to be employed on this project will be WABO certified for the type of work they are to
inspect. If inspection is for work that is not covered by the WABO categories, or the inspector is not WABO
certified, a detailed resume of the inspector and firm must be submitted. The resume must show that the inspector
and the firm are qualified by education and experience to perform the work and testing required by the project
design and specifications.
The work shall be inspected for conformance with the plans and specifications approved by the City. Revisions
and addenda sheets will not be used for inspection, unless they have been approved by the City. Inspection
records shall include:
• A daily record to be maintained on site, itemizing the inspections performed. Any nonconforming work
shall be brought to the irrunediate attention of the contractor for resolution.
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A weekly report shall be submitted to the City; detailing the inspections and testing performed, listing any
nonconforming work and resolution of nonconforming items.
A final report shall be submitted to the building department prior to the Certificate of Occupancy being
issued. This report will indicate that inspection and testing was completed in conformance with the
approved plans, specifications and approved revisions or addenda. Any unresolved discrepancies must be
detailed in the final report.
Contractor:
The contractor shall provide the special inspector or agency adequate notification of work requiring inspection.
The City approved plan and specifications must be made available, at the jobsite for the use of the special
inspector and the City inspector. The contractor shall maintain all daily inspection reports, on site, for review by all
parties.
The special inspection functions are considered to be it addition to the normal inspections performed by the City
and the contractor is responsible for contacting the City to schedule regular inspections. No concrete shall be
poured or other work covered until approval is given by the City inspector.
Building Department:
The building department shall review any revisions and addenda. The City inspector will monitor the special
inspection functions for compliance with the agreement and the approved plans. The City inspector shall be
responsible for approving various stages of construction to be covered and for work to proceed.
Design Professionals:
The architect and/or engineer will clearly indicate on the plans and specifications the specific types of special
inspection required and shall include a schedule for inspection and testing. The architect and/or engineer will
coordinate their revision and addenda process in such a way as to ensure that all required City approvals are
obtained, prior to work shown on the revisions being performed in the field.
Owne r•
The project owner, or the architect or engineer acting as the owners agent, shall employ the special inspector or
agency.
ENFORCEMENT
A failure of the special inspector or firm to perform in keeping with the requirements of the IBC, the approved
plans and this docurnent, may void this agreement and the Building Official's approval of the special inspector. In
such a case a new special inspector and/or firm would need to be proposed for approval. A failure of the design
and/or construction parties to perform in accordance with this agreement may result ii a STOP WORK notice
being posted on the project until nonconforming items have been resolved.
ACKNOWLEDGMENTS
I have read and agree to comply with the terms and conditions of this agreement.
Owner: Travis Alexander
Claire Alexander
Contractor: Jon Killan
Arch./Eng: Cobalt, Phil Haberman
.Signature
Travis alexander
Claire Alexander2/17/22
Signature
Jonathan F. Killin
_Signature
below
Date
Date:
Date:
Special I isp. �`' jt 1 Signature — "" Dat
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Special Insp. Agency 6 "1� G
ACCEPTED FOR THE CITY OF EDMONDS /BUILDING DIVISION
By: Qi�/� fi00li� /Qi�G� Date:03/18/2022
�/` Signature: CCacre ;J A�exa'u%r
Signature: Travis Alexander (Feb 17, 202209:16 EST) Claire J Alexander(Feb 17, 202208:27 EST)
Email: cruxrj@gmail.com Email: emailme@ctairejalexander.com
Signature: Tona-fhan F K1111n
Jonathan F. Killin (Feb 16, 202213:54 PST)
Email: jon@jckillin.com
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Alexander - Haberman Special Inspection
Final Audit Report 2022-02-17
Created: 2022-02-16
By: Steve Hall (reviveproperties@comcast.net)
Status: Signed
Transaction ID: CBJCHBCAABAAC_WHNW20vVrq_3uavCZR6sPugOuhXjJh
"Alexander - Haberman Special Inspection" History
Document created by Steve Hall (reviveproperties@comcast.net)
2022-02-16 - 4:59:00 PM GMT- IP address: 73.225.197.3
Document emailed to Travis Alexander (cruxrj@gmail.com) for signature
2022-02-16 - 5:00:01 PM GMT
Document emailed to Claire J Alexander (emailme@clairejalexander.com) for signature
2022-02-16 - 5:00:01 PM GMT
Document emailed to Jonathan F. Killin (jon@jckillin.com) for signature
2022-02-16 - 5:00:01 PM GMT
Email viewed by Claire J Alexander (emailme@clairejalexander.com)
2022-02-16 - 5:00:07 PM GMT- IP address: 66.102.8.11
Email viewed by Jonathan F. Killin (jon@jckillin.com)
2022-02-16 - 5:28:02 PM GMT- IP address: 104.28.111.46
cyo Document e-signed by Jonathan F. Killin (jon@jckillin.com)
Signature Date: 2022-02-16 - 9:54:10 PM GMT - Time Source: server- IP address: 98.203.153.229
rJo Document e-signed by Claire J Alexander (emailme@clairejalexander.com)
Signature Date: 2022-02-17 - 1:27:28 PM GMT - Time Source: server- IP address: 166.205.147.39
Email viewed by Travis Alexander (cruxrj@gmail.com)
2022-02-17 - 2:10:59 PM GMT- IP address: 66.249.83.63
Document e-signed by Travis Alexander (cruxrj@gmail.com)
Signature Date: 2022-02-17 - 2:16:31 PM GMT - Time Source: server- IP address: 107.116.79.83
40 Agreement completed.
2022-02-17 - 2:16:31 PM GMT
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