City of Philadelphia Department of Licenses & Inspections

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

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 PERIODICFabrication of structural load-bearing members and assemblies (1704.2)

City State ZIP

Fabrication of Pre-Cast Concrete (1704.2.1)

Fabrication process of prefabricated wood structural elements and assemblies (1704.6 and 2303)

Steel: Welding

Decking

Weld Filler Materials

Steel Frame Joint Details

High Strength Bolts, Nuts, and Washers

Reinforcing Steel

Concrete: Materials

Reinforcing Steel

Formwork

Pre-cast Concrete Erection

Post-tension Concrete

Shotcrete Application

Prestressed Concrete

In-situ Concrete Strength

Post-Installed Concrete Anchors

Building Services Unit, MSB Concourse 1401 John F. Kennedy Blvd. Philadelphia, PA 19102

Owner's E-Mail Address Owner's Fax #:

PAGE 1 of 3

OFFICE USE ONLY Date Received: Application Number:

(1704.3, and Table 1704.3)

(1704.4, and Table 1704.4)

October 2014

Masonry: Structural Walls (1704.11and 2104)

Retaining Walls (1704.11 and 1807)

Existing Site Soil Conditions, Fill Placement, Load Bearing Requirements (1704.7, 1803, and 1804, and Table 1704.7)

Driven deep/Cast-in-place deep/Helical pile/Vertical masonry foundations (1704.8, 1704.9, and 1704.10, 1704.11, and

Tables 1704.8 and 1704.9)

Spray Fire-Resistant Materials, Mastic & Intumescent Coatings (1704.12, 1704.13)

Exterior Insulation and Finish Systems (EIFS) (1704.14)

Special Cases (Attach separate sheet, if necessary) (1704.15)

Underpinning (See Appendix B of Special Inspections Program)

Demolition (3303 as amended, 1704.15 as amended)

Smoke Control Systems (1704.16, 909, 909.18.8 and 909.19)

Seismic Resistance (1707, and 1705.3.1 through 1705.3.6 inclusive)

(CONTINUED FROM PREVIOUS PAGE)

PERIODICCONTINUOUSREQUIREDVERIFICATION AND INSPECTION ITEM

Excavation and Filling (1704.7, 1804, 1805, and 3304)

(1704.5, and Tables 1704.5.1 and 1704.5.3)

PAGE 2 of 3 Statement of Special Inspections Schedule (Rev. October 2014)City of Philadelphia

Department of Licenses and Inspections

Table

Table

Inspection ItemTable

Inspection Item

Table Inspection Item

Inspection Item

Inspection ItemTable

Inspection ItemTable

If the project includes construction activities that require special inspections which are not specifically listed above, please add the special inspection item (per special inspection tables listed in Chapter 17, or as required by the design professional of record), the applicable code reference, and whether inspections are to be continuous or periodic, on the lines below.

PAGE 3 of 3 Statement of Special Inspections Schedule (Rev. October 2014)

City of Philadelphia Department of Licenses and Inspections

E-Mail Address:

DESIGN PROFESSIONAL IN RESPONSIBLE CHARGE OF SPECIAL INSPECTIONS (DPRC-SI)

By affixing professional seal below, the DPRC-SI confirms that he/she has consulted with the appropriate design professional(s) of record to determine the construction activities covered by the subject permit that require special inspections in accordance with

2009 IBC Chapter 17. (For other Duties and Responsibilities of the DPRC-SI, refer to the Duties and Responsibilities Agreement.) Affix seal in space below.

Professional Engineer Registered Architect

Name: (Print) Phone #:

Address:

Fax #:City State ZIP