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200 S. Anaheim Blvd., Suite 145 Anaheim, California 92805 (714)765-5153 Phone (714)765-4607 Fax www.anaheim.net/building AUG I 2019 B702 CITY OF ANAHEIM PLANNING DEPARTMENT BUILDING DIVISION SPECIAL INSPECTOR ANNUAL REGISTRATION FORM DATE: ANNUAL FEE $53.00 SPECIAL INSPECTOR INFORMATION Name: Address: City: Phone Number: Email Address: Present Employer: Employer’s Address: City: Phone Number: All certifications listed below must be current and valid. Legible copy(s) must be attached to this registration, including a California driver’s license. DISCIPLINE ICC LA CITY ORANGE COUNTY OTHER Concrete Field Testing Structural Masonry Reinforced Concrete * Pre-stressed Concrete Structural Steel/Welding Fireproofing HERS Other * Including Epoxy Anchors I hereby certify that I am qualified by training and experience to perform the inspections for which I hold the above listed Special Inspector’s certifications. I will certify that the job conditions are in conformance with the approved plans and job specifications. If at any time, progress occurs on the jobsite under my responsibility, without my knowledge or approval, or if I terminate my services for the assigned scope of my responsibility, I will immediately notify both the project superintendent and the City of Anaheim Building Division in writing. A record of my test and/or inspections as certified to the above will be submitted to the Building Division in writing at regular intervals. I will also provide a final letter certifying satisfactory completion. I understand that I shall be employed only by the Owner, Architect or Engineer of Record. I understand that it is my responsibility to provide the address and building permit number of all future projects to the Anaheim Building Division prior to special inspections. Phone: [PHONE REDACTED] ext. 0 Fax: [PHONE REDACTED] Email: SPECIAL INSPECTOR SIGNATURE DATE BUILDING DIVISION SIGNATURE DATE