HomeMy WebLinkAboutStatement of Special Inspections - FillablePermit No.:
Department of Community Development
Permit Center
Mailing Address: 216 Prospect Street, Port Orchard, WA 98366
Office is located at 720 Prospect Street
permitcenter@portorchardwa.gov
(360) 874-5533
Statement of Special Inspections
Permit Type:
Site Address / Location:
Project Description:
Primary Contact (Authorized Agent / Applicant):
Name:
Mailing Address:
City, State, Zip Code:
Phone:
Email Address:
Complete the following information. Additional lines may be added, or sheets may be used. Attach
relevant and/or documentation attached.
Per 2021 IBC 1704.3.1:
For each special inspection, identify whether it will be continuous, periodic or performed in accordance
with the notation used in the referenced standard where the inspections are defined.
Materials, systems, components and work required:
Type and extent of each special inspection:
Type and extent for each test:
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Seismic requirements: Where specified in Section 1705.12 or 1705.13, identify the designated seismic
systems and seismic force -resisting systems that are subject to the special inspections or tests:
Wind requirements: Where specified in Section 1705.11, identify the main windforce-resisting systems
and wind -resisting components that are subject to special inspections:
Per 2021 IBC 1704.2.1, we are providing documentation of the competence and relevant experience
or training of the special inspectors who will perform the special inspections and tests during
construction.
Special Inspector Name:
Company Name:
Mailing Address:
Email:
Phone No.
Relevant experience or training: (complete or attach documentation)
Prepared by Registered Design Professional in Responsible Charge*:
Name:
Company Name:
Mailing Address:
Email:
Phone No.
The electronic signature below is equivalent to a handwritten signature and is binding for all purposes.
Signature:
Date:
*The statement of special inspections is permitted to be prepared by a qualified person approved by the building
official for construction not designed by a registered design professional. Check with the Permit Center prior to
submitting.
The information on this form and associated documents are considered public records and subject to public disclosure laws in Chapter 42.56 RCW
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