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

Weld Filter Materials

Steel Frame Joint Details

High Strength Bolts, Nuts, and Washers

Reinforcing SteelConcrete: Materials

Reinforcing Steel

Formwork

Pre-cast Concrete Erection

Post-tension Concrete

Shortcrete 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 #:

(CONTINUED ON FOLLOWING PAGE) PAGE 1 of 2

OFFICE USE ONLY Date Received: Application Number:

(1704.3, and Table 1704.3)

(1704.4, and Table 1704.4)

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 form (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)

Design Strength of Materials (1711 as applicable)

Alternate Test Procedures (1712 as applicable)

PAGE 2 of 2 Statement of Special Inspections Schedule (Rev. March 2014)

City of Philadelphia Department of Licenses and Inspections

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

Professional Engineer Registered Architect

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.

Name: (Print) Phone #:

Address:

Street

City State ZIP

E-Mail Address: Fax #:

PERIODICCONTINUOUSREQUIREDVERIFICATION AND INSPECTION ITEM

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

(1704.5, and Tables 1604.5, 1704.5.1 and 1704.5.3)