STATEMENT OF SPECIAL INSPECTIONS SCHEDULE …

1 OFFICE USE ONLY. City of Philadelphia Date Received: Department of Licenses & INSPECTIONS building Services Unit, MSB Concourse Application Number: 1401 John F. Kennedy Blvd. Philadelphia, PA 19102. STATEMENT OF SPECIAL INSPECTIONS SCHEDULE . ( international building code ). In accordance with the provisions of Chapter 17 of the 2009 international building code , this form is to list the SPECIAL INSPECTIONS as required for the proposed construction located at: ADDRESS (Print): Owner's Name (Print): Owner's Phone #: Owner's Address: Street City State ZIP. Owner's E-Mail Address Owner's Fax #: The design professional in responsible charge of SPECIAL INSPECTIONS (DPRC-SI) shall indicate by a checkmark which of the SPECIAL INSPECTIONS below are required for the above mentioned construction site: VERIFICATION AND inspection ITEM REQUIRED CONTINUOUS PERIODIC. Fabrication of structural load-bearing members and assemblies ( ). Fabrication of Pre-Cast Concrete ( ). Fabrication process of prefabricated wood structural elements and assemblies ( and 2303).

2 Steel: Welding ( , and Weld Filter Materials Table ). Steel Frame Joint Details High Strength Bolts, Nuts, and Washers Reinforcing Steel Concrete: Materials ( , and Reinforcing Steel Table ). Formwork Pre-cast Concrete Erection Post-tension Concrete Shortcrete Application Prestressed Concrete In-situ Concrete Strength Post-Installed Concrete Anchors (CONTINUED ON FOLLOWING PAGE) PAGE 1 of 2. (CONTINUED FROM PREVIOUS PAGE). VERIFICATION AND inspection ITEM REQUIRED CONTINUOUS PERIODIC. Masonry: Structural Walls ( 2104). ( , and Tables Retaining Walls ( and 1807). , and ). Existing Site Soil Conditions, Fill Placement, Load Bearing Requirements ( , 1803, and 1804, and Table ). Driven deep/Cast-in-place deep/Helical pile/Vertical masonry foundations ( , , and , , and Tables and ). Excavation and Filling ( , 1804, 1805, and 3304). Spray Fire-Resistant Materials, Mastic & Intumescent Coatings ( , ). Exterior Insulation and Finish Systems form (EIFS) ( ). SPECIAL Cases (Attach separate sheet, if necessary) ( ).

3 Underpinning (See Appendix B of SPECIAL INSPECTIONS Program). Demolition (3303 as amended, as amended). Smoke Control Systems ( , 909, and ). Seismic Resistance (1707, and through inclusive). Design Strength of Materials (1711 as applicable). Alternate Test Procedures (1712 as applicable). DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE OF SPECIAL INSPECTIONS (DPRC-SI). Responsible for maintaining records of all INSPECTIONS ; furnishing reports to the building Inspector; and verifying that the SPECIAL inspector for each required item above is qualified to perform that inspection . Seal to affixed in space below. Professional Engineer Registered Architect Name: (Print) Phone #: Address: Street City State ZIP. E-Mail Address: Fax #: City of Philadelphia PAGE 2 of 2. Department of Licenses and INSPECTIONS STATEMENT of SPECIAL INSPECTIONS SCHEDULE (Rev. March 2014).