Structural Observation Agreement - City Of Tukwila Building Division Page 7
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14City of Tukwila
Building Division
Building Permit Number: __________________
Special Inspector Qualification Form
Each special inspector making inspections for any inspecting/testing agency shall complete this form
and enclose a work experience resume for the past five (5) years.
Inspector Information:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City, State, Zip: ______________________________________________________________________
Office Phone: ________________________
Cell Phone: ________________________________
Inspection Classification: _______________________________________________________________
Current ICC and/or WABO Number(s): _____________________
Expiration Date: __________
Project Name: ________________________________________________________________________
Project Address: ______________________________________________________________________
STATEMENT OF UNDERSTANDING
I, ____________________________________ hereby affirm that I have been employed by:
____________________________________________________________________________________
(Agency/Firm)
____________________________________________________________________________________
(Address)
To perform special inspection at above stated project and that I am aware that in performing this
inspection, I am acting as an agent for the City of Tukwila and I am responsible to the building official. I
am aware that my duties include compliance with the approved plan(s), specifications, the I.B.C. and
recognized construction practices, which do not conflict with any of the aforementioned documents. I
will submit written reports to the building official as required.
Signature: _________________________________________
Date: _________________________
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