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City of San Diego

Application

Inspection Services Division

Planning and Development Review

to Perform

9601 Ridgehaven Court • Suite 220 • MS 1102-B

San Diego, CA 92123

Off-Site Fabrication

Information (858) 492-5070 • FAX (858) 492-5098

(MUST BE FILED ONE BUSINESS DAY PRIOR TO SCHEDULED FABRICATION COMMENCEMENT DATE)

DATE __________________________ SCHEDULED FABRICATION COMMENCEMENT DATE ___________________________

FABRICATION CO. NAME _____________________________________________ TELEPHONE NO. (_______) _______________

FABRICATION SHOP ADDRESS ______________________________________________ FAX NO. (_______) _______________

San Diego

CITY ________________________________________________ STATE ____________________ ZIP CODE _______________

BUILDING PERMIT NO./S ______________________________ PLAN FILE NO. ________________________________________

(For projects with multiple permit numbers but with the same plan file number, you may list all permit numbers and addresses on a separate sheet.)

JOB SITE ADDRESS _________________________________________________________________________________________

DESCRIPTION OF COMPONENTS TO BE FABRICATED ___________________________________________________________

__________________________________________________________________________________________________________

FABRICATOR IS CURRENTLY CERTIFIED BY (refer to BNL 17-6):

ICBO

AISC

ACI

PCI

pti

Other ___________________________________

Certificate No. _____________________ Expiration Date ______________

SPECIAL INSPECTOR ASSIGNED

Certificate No. ___________________

(BY BUILDING OWNER) _____________________________________

(Not required for a fabricator registered and approved by the City of San Diego, unless otherwise noted on the approved permitted plans and specifications.)

FABRICATION DRAWINGS REVIEWED AND ACCEPTED BY DESIGNER OF RECORD?

YES

NOTE: THE FABRICATOR IS REQUIRED TO HAVE FABRICATION DRAWINGS WHICH HAVE BEEN REVIEWED AND ACCEPTED BY THE DESIGNER OF

RECORD. SPECIAL INSPECTOR MUST VERIFY SUCH ACCEPTANCE PRIOR TO COMMENCING INSPECTION DUTIES.

AGREEMENT

We hereby agree to have continuous special inspection, sampling and testing as specified on the approved permitted plans and specifications. We will further

agree that the work will be performed in the manner prescribed by the California Building Code and the Standards as amended by The City of San Diego and

other regulations.

We understand that the property owner or the engineer / architect of record acting as the property owner’s agent is solely responsible for employment of one or

more special inspectors who shall provide inspections for fabrication of the components described herein. We also agree to provide unlimited access to the

fabrication areas, the material storage and mixing areas, other related areas, the approved shop drawings and other documents for the purpose of inspection,

sampling and testing by the special inspectors, construction materials testing laboratory or Planning and Development Review personnel during normal working

hours. We further agree to provide an identifying mark on each fabricated member

or component shipped to the construction site. A certificate of compliance and a

FOR OFFICE USE ONLY

shipping list shall accompany each shipment and a copy shall be sent to the

Inspection Services Division and the architect or engineer of record when the

components are shipped.

APPROVED

DENIED

This agreement is limited to fabrication of the components or members described

CORRECT AND RESUBMIT

above to be used in the structures identified by the permit numbers shown and is

not transferrable to any other fabrication work or other construction sites.