Forms. VR Form 1 - Special Inspector Roster and Contact Information 2. VR Form 2 - Participating Jurisdiction Roster and Contact Information 5

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1 Chapter Forms Page 1 VR Form 1 - Special Inspector Roster and Contact Information 2 VR Form 2 - Participating Jurisdiction Roster and Contact Information 5 VR Form 3 - Application - Recognized Special Inspector N/A VR Form 4 - Application Resume/ Employment History Sample N/A VR Form 5 - Special Inspector Reference Verification N/A VR Form 6 - Special Inspector Application Determination N/A VR Form 7 - Change of Address Form N/A VR Form 8 - Credit Card Renewal Authorization N/A VR Form 9- Inspection Report Daily, Weekly or Final 6 VR Form 10 - Discrepancy Report 8 VR Form 11 - Final Report 10 VR Form 12a - Statement of Special Inspections 12 VR Form 12b - Statement of Special Inspection Periodic and Continuous Inspection Schedule 15 VR Form 13 - Statement of Special Inspection Agreement 18 VR Form 14 - Special Inspection Record 19 VR Form 15 - Plan Check Correction Comment Form 20 VR Form 16 - Interdepartmental Communication Form N/A VR Form Template Future Forms N/A 1 Page number indicated as N/A, indicates a form is not applicable to the City of Calabasas special inspection policy. Page 1 of 20

2 Special Inspector Roster and Contact Information VR Form 1 Page 1 of 3 Page 2 of 20

3 Special Inspector Roster and Contact Information VR Form 1 Page 2 of 3 Page 3 of 20

4 Special Inspector Roster and Contact Information VR Form 1 Page 3 of 3 Page 4 of 20

5 Participating Jurisdiction Roster and Contact Information City of Agoura Hills Mike Kalske, Sr. Building Inspector (818) or 7334 VR Form 2 City of Calabasas Ruben Flores, Sr. Building Inspector (818) rflores@cityofcalabasas.com City of Camarillo (805) City of Fillmore Larry Beem CBO, Deputy Building Official (805) x114 City of Malibu Craig George, Deputy Building Official (310) cgeorge@malibucity.org City of Moorpark Ray Young, Building Official (805) City of Ojai Larry Beem CBO, Deputy Building Official (805) x112 City of Oxnard Steve Newman, Building & Engineering Services steve.newman@ci.oxnard.ca.us (805) City of Port Hueneme Steve Sutton, Building Official (805) ssutton@cityofportgueneme.org County of Ventura Building and Safety Dave Hanson, District Supervisor (805) City of San Buena Ventura Yolanda Bundy, Deputy Building Official Building and Safety (805) ybundy@cityofventura.net City of Simi Valley Dave Austin (805) daustin@simivalley.org City of Santa Paula Building and Safety Mike Leach, Chief Building Official (805) ex. 252 City of Thousand Oaks Steve Stoltze, Building Inspection Supervisor (805) sstoltze@toaks.org Page 5 of 20

6 Inspection Report Daily, Weekly or Final VR Form 9 Page 1 of Jurisdiction Building Permit Number Address Daily Report Weekly Report Final Report General Contractor Structural Engineer Inspection frequency- check one: Periodic Continuous Type of Inspection - check one: Reinforced Concrete Shotcrete Prestressed Concrete Masonry For any of the above insert Mix Design No. PSI: Welding: High-strength Bolts Epoxy Other Welder Name/s Describe Below Off Site Fabricator Time present at project; location and description of work inspected: Date (Insert additional pages if necessary) To the best of my knowledge, the work that I have inspected has been completed per the stamped, approved plans and the requirements of the California Building Code pertaining to special inspections. Inspectors Name Print Inspectors Signature Date Page 6 of 20

7 Inspection Report Daily, Weekly or Final VR Form 9 (Additional Page/s) Page of To the best of my knowledge, the work that I have inspected has been completed per the stamped approved plans and the requirements of the California Building Code pertaining to special inspections. Inspectors Name Print Inspectors Signature Date Page 7 of 20

8 Inspection Discrepancy Report VR Form 10 Page of Jurisdiction: Permit No: Date: Project Address: Project Name Special Inspection Type Continuous Periodic; described frequency: Notice delivered to: Contractor Engineer/Architect Building Department Describe (i) deviations from, or lack of information within the approved construction plans; or (ii) deviations from project specifications or engineered reports; or (iii) deviations pertaining to the California Building Code or (iv) other deviation or need for subsequent information: Make the following corrections and secure inspection approval prior to proceeding with this phase of the work: (Include additional pages if necessary) Inspectors Name Print Date Inspectors Signature Post with building permit inspection record card DO NOT REMOVE THIS NOTICE Page 8 of 20

9 Inspection Discrepancy Report VR Form 10 (Additional Page/s) Page of Inspectors Name Print Date Inspectors Signature Page 9 of 20

10 Final Report of Special Inspections Special Inspector VR Form 11 This form shall be submitted when all the special inspection requirements for a project have been fulfilled. Each special inspector who has performed a special inspection identified within the Schedule of Special Inspection Services is required to complete this form related to their scope of work and submit a copy to the design license professional in responsible charge and the participating jurisdiction. The special inspection program will not be considered complete until all forms from all agents have been approved by the design license professional in responsible charge. Final documents from the design license professional in responsible charge must be approved by the participating jurisdiction. Jurisdiction Building Permit Number Address Describe completed scope of special inspections as detailed within the Statement of Special Inspections Special Inspector Print Date Signature Design License Professional in Responsible Charge Print Date Signature Page 10 of 20

11 Statement of Special Inspections VR Form 12a page of Project Information The following information should be included in the statement of special inspections: Project Address: Permit/Plan Check No: Engineer and Architect Building Permit Scope of Work Describe all work that requires special inspections and denote whether required inspections and verifications of materials are continuous or periodic (for larger projects see VR Form 12b): Design License Professional in Responsible Charge Print Signature Date Page 11 of 20

12 Statement of Special Inspections VR Form 12a page of The following information should also be included in the statement of special inspections: See Model Program Helpful Guidelines Section 5.4. Design Professional which states, in pertinent part: Special inspection record (see VR Form 14) should be prepared by the design professional, approved by the participating jurisdiction and should be maintained at the project site with the approved construction plans, permits and other inspection records. The special inspection record should be utilized to record a special inspector s presence on the project site for each day s inspection. When the type of special inspection in the schedule is completed for the last time on the project, the special inspector, firm or agency that performed the final inspection or test of that item should sign and date the record and indicate that the category of special inspection is complete. Final report of special inspections. The special inspectors final report of special inspections should be reviewed and signed by the design professional after all special inspection requirements for a project have been fulfilled. Each special inspector corresponding to a discipline depicted within the statement of special inspections should be required to complete a separate form for submittal to the design professional. Once the final documents are approved by the design professional, they should then be submitted to the building official for approval. The special inspection Program may not be considered complete until all forms from all agents have been submitted, received and approved by the participating jurisdiction. The following information should be included in the statement of special inspections: Duties and Responsibilities of the Special Inspector See Model Program Helpful Guidelines Section 5.1, which states, in pertinent part: Certifications. All special inspectors should be certified in their areas of expertise. Except for smoke control, minimum qualifications include certification from an approved agency or organization. Those approved agencies or organizations include, but are not necessarily limited to: (i) International Code Council, (ii) The City of Los Angeles Department of Building and Safety, (iii) The County of Los Angeles Department of Building and Safety, (iv) AWS, (v) IAS and (vi) HERS Rater Certification Conduct. When performing a special inspection on a project that requires building permits, special inspectors are a reflection of the participating jurisdiction charged with administering the building code. In as much, it is imperative all special inspectors conduct themselves in a professional and fair manner while being diligent and conscientious at the same time. The guidelines here within should not be construed to be the limitations of ethical conduct and problem resolution techniques; moreover, the unique aspects of construction cannot always be anticipated and these guidelines are intended to be flexible for the participating jurisdictions needs. Accordingly, a participating jurisdiction may deem a very small project is not subject to the full scope of the guidelines, while a very large and complex project may be subjected to additional criteria. To ensure smooth relations with any participating jurisdiction, special inspectors are encouraged to communicate with the participating jurisdictions in a proactive manner A Special Inspector is not to be employed by the contractor or any subcontractor. Page 12 of 20

13 Statement of Special Inspections VR Form 12a page of Duties and Responsibilities of the Special Inspector (Continued) Special Inspectors are responsible to the participating jurisdiction for assuring compliance with approved plans, specifications and the CBC. All discrepancies should be bought to the immediate attention of the contractor for correction. If discrepancies are not immediately corrected, they should be brought to the attention of the proper design authority and to the building official of the participating jurisdiction Chain of command. The special inspectors immediate superior in the participating jurisdiction, while employed as a special inspector, is the building official or the building official s designee Advanced notice to participating jurisdiction. As detailed within this section, advanced notice to the building official of the related participating jurisdiction prior to commencing an initial special inspection at any project in that jurisdiction should not be optional. Advanced notice should be provided via verbal contact or other form of communication acceptable to the participating jurisdiction (IE: Fax, or voic .) Advanced notice is preferred at least one working day prior to commencing the special inspection and in no case should it ever be later than 8:00 A.M. the morning of the scheduled inspection. When notifying the participating jurisdiction of a pending special inspection, the special inspector should provide the following information: a. The project address; b. Special inspector s name and cell phone number; c. Registration number; d. Type of work to be inspected, and e. The date and time they will be on the project site Advanced notice to participating jurisdiction Direct communications. When policy and procedure of a participating jurisdiction, advanced notice detailed above should be made by speaking directly to the participating jurisdictions building inspector of record or their immediate supervisor Safety, tools and equipment. Special Inspectors should not work in an unsafe manner or in an unsafe environment. Special inspectors should have in their possession all necessary tools, equipment and testing devices to enable the performance of their duties and to perform the inspections in an effective and safe manner Job Performance Notice to Contractor. The special inspector should notify the contractor of both their presence at the project site and the scope of their responsibilities when making their initial visit to the project site. They should clearly describe to the contractor their responsibility to ensure conformance with the approved plans, specifications, the building code and whether they are required to perform continuous or periodic inspections. Page 13 of 20

14 Statement of Special Inspections VR Form 12a page of Duties and Responsibilities of the Special Inspector (Continued) While the special inspector is engaged performing special inspections, the special inspector should not undertake or engage in any task that will interfere with the proper performance of the duties of such inspection. When the CBC requires an inspection by a special inspector, the special inspector should maintain their presence on the project site and should not be engaged, employed or act in a manner that would prohibit full concentration of the task at hand. Special inspectors should be present during the execution of all work required to be inspected. In this context, present is construed to mean being at the specific location of the work in progress and in no case should the inspector be out of sight of the work. Should any emergency arise that requires the special inspector to be absent from the project site while work is in progress, he/she should notify the participating jurisdiction. When said circumstances arise, work requiring special inspection should be stopped until the owner has obtained the services of a substitute special inspector or has otherwise been directed to recommence work by the participating jurisdiction Special inspection approval or progress reports (see VR Form 9.) Special inspectors should prepare and provide timely inspection approval, progress, discrepancy or final reports utilizing appropriate forms. All reports should be provided directly to the design professional in responsible charge and the contractor. Special inspection one-day-one-stop approvals and repetitive special inspection progress approvals should include, but not be limited to: a. Description of the special inspections, the location of the inspection and any test made; b. Indication of nonconforming issues or discrepancies items that were resolved and the corrective action that was implemented; c. Itemization of any changes authorized by the design professional, and d. Indication of the time arrived at any project and the time departed from the project each and every day the special inspector is preforming special inspections Discrepancy report (see VR Form 10.) When discrepancies are not immediately corrected and or otherwise need resolution, special inspectors should prepare and provide timely discrepancy reports. All discrepancy reports should be provided directly to the design professional in responsible charge and the contractor. The special inspector should describe each nonconforming item in detail. The description should include, but not be limited to (i) the exact location of the discrepancy within the project, (ii) the related CBC section and or (iii) approved plan or specification deviation Final report (see VR Form 11.) When a project requires multiple special inspections, the special inspector should submit a final signed report stating all required special inspections and testing were fulfilled and reported and that any outstanding discrepancies have been corrected. When required by the statement of special inspections, a copy of the final report should be submitted to the design license professional in responsible charge. Once the final documents are approved by the design license professional in responsible charge, they should be submitted to the building official for approval. The special inspection Program may not be considered complete until forms from all agents have been submitted, received and approved by the participating jurisdiction. Design License Professional in Responsible Charge Print Signature Date Page 14 of 20

15 Statement of Special Inspection Periodic and Continuous Inspection Schedule VR Form 12b Page of Steel Construction Verification / Inspection See Table Required Verification and Inspection of Steel Construction Continuous Periodic 1. Material verification of high-strength bolts, nuts and washers a. Identification markings to conform to ASTM standards specified in the approved --- X construction documents. b. Manufacturer s certificate of compliance required --- X 2. Inspection of high-strength bolting a. Snug-tight joints. --- X b. Pretensioned and slip-critical joints using turn-of-nut with matchmarking, twist-off bolt or direct tension indicator methods of installation. --- X c. Pretensioned and slip-critical joints using turn-of-nut without matchmarking or calibrated wrench methods of installation. X Material verification of structural steel and cold-formed steel deck: a. For structural steel, identification markings to conform to AISC X b. For other steel, identification markings to conform to ASTM --- X Standards specified in the approved construction documents. c. Manufacturer s certified test reports. --- X 4. Material verification of weld filler materials: a. Identification markings to conform to AWS specification in the approved --- X construction documents. b. Manufacturer s certificate of compliance required. --- X 5. Inspection of welding: a. Structural steel and cold-formed steel deck: 1. Complete and partial joint penetration groove welds X Multipass fillet welds X Single-pass fillet welds >5/16 X Plug and slot welds. X Single-pass fillet welds <5/ X 6. Floor and roof deck welds --- b. Reinforcing steel: 1. Verification of weldability of reinforcing steel other than ASTM A X 2. Reinforcing steel resisting flexural and axial forces in intermediate and special moment frames, and boundary elements of special structural walls of concrete X --- and shear reinforcement. 3. Shear reinforcement X Other reinforcing steel --- X 6. Inspection of steel frame joint details for compliance d. Details such as bracing and stiffening --- X e. Member locations. --- X f. Application of joint details at each connection. --- X Page 15 of 20

16 Statement of Special Inspection Periodic and Continuous Inspection Schedule VR Form 12b Page of Concrete Construction Verification / Inspection Continuous Periodic See Table Required Verification and Inspection of Concrete Construction 1. Inspection of reinforcing steel welding in accordance with Table , Item 5b. --- X 2. Inspection of bolts to be installed in concrete prior to and during placement of concrete where allowable loads have been increased or where strength design is used. X Inspection of anchors installed in hardened concrete. --- X 4. Verifying use of required design mix. --- X 5. At the time fresh concrete is sampled to fabricate specimens for strength tests, perform slump and air content tests, and determine the temperature of the concrete. X Inspection of concrete and shotcrete placement for proper application techniques. X Inspection for maintenance of specified curing temperatures and techniques. X Inspection of prestressed concrete: a. Application of prestressing forces. X --- b. Grouting of bonded prestressing tendons in the seismic-force-resisting system X Erection of precast concrete members. --- X 10. Verification of in-situ concrete strength, prior to stressing of tendons in posttensioned concrete and prior to removal of shores and forms from beams and structural slabs. --- X 11. Inspect framework for shape, location and dimensions of the concrete member being formed. --- X Masonry Level 1 Verification / Inspection See Table Level 1 Special Inspection 1. Compliance with required inspection provision of the construction documents and the --- X approved submittals shall be verified. 2. Verification of f m and f AAC prior to construction except where specifically exempted --- X by this code. 3. Verification of slump flow and VSI as delivered to the site for self-consolidating grout. X As masonry construction begins, the following shall be verified to ensure compliance: a. Proportions of site-prepared mortar. --- X b. Construction of mortar joints. --- X c. Location of reinforcement, connectors, prestressing tendons and anchorages. --- X d. Prestressing Technique. --- X e. Grade and size of prestressing tendons and anchorages. --- X 5. During construction the inspection program shall verify: a. Size and location of structural elements. --- X b. Type, size and location of anchors, including other details of anchorage of masonry --- X to structural members, frames or other construction. c. Specified size, grade and type of reinforcement, anchor bolts, prestressing tendons --- X and anchorages. d. Welding of reinforcing bars. X --- e. Preparation, construction and protection of masonry during cold weather (temperature below 40 degrees F) or hot weather (temperature above 90 degrees F). --- X f. Application and measurement of prestressing force. X Prior to grouting, the following shall be verified to ensure compliance: a. Grout space is clean. --- X b. Placement of reinforcement and connectors, and prestressing tendons and --- X anchorages. c. Proportions of site-prepared grout and prestressing grout for bonded tendons. --- X Page 16 of 20

17 Statement of Special Inspection Periodic and Continuous Inspection Schedule VR Form 12b Page of Masonry Level 1 Verification / Inspection (Continued) Continuous Periodic d. Construction of mortar joints. --- X 7. Grout placement shall be verified to ensure compliance: X --- a. Grouting of prestressing bonded tendons. X X 8. Preparation of any required grout specimens, mortar specimens and/or prisms shall be observed. --- X Soils Verification / Inspection See Table Verify materials below shallow foundations are adequate to achieve the design bearing capacity. --- X 2. Verify excavations are extended to proper depth and have reached proper material. --- X 3. Perform classification and testing of compacted fill materials. --- X 4. Verify use of proper materials, densities and lift thicknesses during placement and compaction of compacted fill. X Prior to placement of compacted fill, observe subgrade and verify that site has been --- X prepared properly. Deep Driven Foundation Elements Verification / Inspection See Table Verify element materials, sizes and lengths comply with the requirements. X Determine capacities of test elements and conduct additional food tests, as required. X Observe driving operations and maintain complete and accurate records for each element. X Verify placement locations and plumbness, confirm type and size of hammer, record number of flows per foot of penetrations, determine required penetrations to achieve design capacity, record tip and butt elevations and document any damage to foundation element. X For steel elements, perform additional inspections in accordance with Section For concrete elements and concrete-filled elements, perform additional inspections in accordance with Section For specialty elements, perform additional inspections in accordance with Section Cast-In-Place Deep Foundation Elements Verification / Inspection See Table Observe drilling operations and maintain complete and accurate records for each element. X Verify placement locations and plumbness, confirm element diameters, bell diameters (if applicable), lengths, embedment into bedrock (if applicable) and adequate end-bearing strata capacity. Record concrete or grout volumes. X For concrete elements, perform additional inspections in accordance with Section X Other Materials Verification / Inspection Other Work Verification / Inspection Design License Professional in Responsible Charge Print Signature Date Page 17 of 20

18 Statement of Special Inspection Agreement VR Form 13 page of International Code Council Model Program Appendix A Section 1 The following should be submitted to the participating jurisdiction prior to permit issuance. I have read and understand my responsibilities in regards to the special inspection program Owner: Registered/Design Professional in Responsible Charge: Contractor: Special Inspector / Special Inspection Agency*: Others as required by Building Official: ACCEPTED FOR THE BUILDING DEPARTMENT Date: Date: Date: Date: Date: Date: *This signature may be that of the Responsible Professional within the special inspection agency. Page 18 of 20

19 Special Inspection Record VR Form 14 Jurisdiction Building Permit Number Address POST THIS SPECIAL INSPECTION RECORD WITH THE BUILDING PERMIT INSPECTION RECORD CARD Each special inspector is to record their presence on the job-site for each day s inspection. Inspection Type Special Inspector Date Notes Time In Time Out Page 19 of 20

20 Special Inspection Plan Check Correction Comment VR Form 15 Page 20 of 20