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Jurisdiction <br />Logo <br />Here <br />t ounty of SA..r* Ar.tft <br />BUILDING DIVISION <br />r 1231456-789'l , F 2341567-8912, E-mait @ <br />STRUCTURAL OBSERVATION REPORT FORM <br />STRUCTURAL OBSERVAT,ON means the visual observation of the structural system, for general conformance to the <br />approved plans and specifications, at signiticant construction stages and at complelion of the structural systam. Structural <br />observation does not include or waive lhe responsibility for the inspections reguired by Section 108, 1701 or other sections ot <br />the Code. <br />Report No <br />This report includes all construction wo* ttrrougn -1troay or ,zoll easeNo. I t I1 <br />*o1oa,6o"'7f,?JZ- e, l{ 5-r.- <br />StructuI'l Ob.crEr of Record (SOR):q'nVe eY-€>tr SOR Phone l{o <br />/Ad7f 7-t't-'t <br />Bulldlng Permit Noptq5611 Obsorvor P.olosslonal Lic./Reg. No.: <br />fGetuz <br />9baarv.r Phon. No.: <br />8/al7r l-tirt <br />OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS <br />WALL FRAMES FLOOR PORTION OBSERVEO, IF NOT WHOLEFOUNDATION <br />O concrete E SloelMomenl Frame O Concrete ftcF? a.3a' ebeg ft-Footlng, S{c#l.dlt <br />O Mrt Foundation O Mrsonry O St6olBrrc6d Frame O St olDock f{tta '/i.- F'I<. tlo:af:- <br />O Cllaaon, Piles, Grad6 B6rms E Wood O Concrota Momonl Faame O Wood 6*tt-|. <br />E Ratrlnlng Foundrtlon <br />Hlllald6 Spocl6l Anchort <br />tr Other:E M!3onry W!ll Frame tr Othors: <br />tr oth.r.I <br />OBSERVED DEFICIENCIES:Nrrt6 ' <br />,I. IAM THE EI{GINEER OR ARCHITECT RETAINED BY IHE OWNER TO BE ITi RESPONSIBLE <br />CHARGE FOR THE STRUCTU <br />or rx4rvEouxw or <br />RAI. OBSERVATION IN ACCOROA|ICE WTTH IHE REOTjIREMENTS <br />JA elr kut <br />2 I, OR ANOTHER ENGIIiEER OR ARCHITECT wl{O I HAVE DESIGI{ATED AAOVE AND IS UNOER <br />MY RESPONSIBLE C}IARGE. HAS PERFORi'ED THE REQUIRED SITE VISITS AT EACH <br />SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN GENERAL <br />CONFORMANCE wlTH APPROVED PLANS AND SPECIFICATIO S; <br />3 <br />1 <br />ALL DEFICIENCIES WHICH REM TO BE CORRECTED HAVE BEEN INDICATEO ABOVE: <br />IRECOMMEN AT ACCE E OF THE STRUCTURAL SYSTEMS BY <br />BE WTHHELD UNTIL ALL OBSERVED OEFICIENCIES <br />ARE RECTEO <br />Z /*tt1 <br />SIGNATURE <br />,<\,rHEt[r/cou I{TY <br />OF <br />STArilP OF STRUCTURAL <br />OBSERVER OF RECORD <br />q <br />gLr E <br />crv <br />mv <br />** <br />2(9 <br />ts <br />F ESS/ <br />oFC <br />sorl doc - LARTJCP Slructural Observatron Report Form (V1 0 - 5/2000) <br />DATE <br />LAR UCP;.\....'.. .'-:.. .CA9 <br />Structural Ob.crvrtlon pG.rormod by:srcv:c *.rreb& <br />O Oth.ra: <br />I DECLARE THAT THE FOLLOWNG STATEMET{TS ARE TRUE TO THE BEST OF MY KNOWLEOGE: <br />No. C06727 <br />ExP.9-30'20 <br />Page 1 of 1