Form 851 - Post-Installed Mechanical Anchorage Clearance Report

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Use of this form serves as a Quality Assurance Agency Special Inspection Agreement between Building Official, Owner and Quality Assurance
Agency for the purposes of special inspection per Section 22.02.515 of the Building Administrative Code of Clark County.
Report
No.
Clark County Department of
Page
Building & Fire Prevention
of
Inspection
Date
4701 W. Russell Rd ~ Las Vegas NV 89118
Permit
(702) 455-3000 ~ Fax (702) 221-0630
No.
Jerome A. Stueve, P.E., Director
Samuel D. Palmer P.E., Assistant
Director 
Girard W. Page, Fire Marshal
POST-INSTALLED MECHANICAL ANCHORAGE CLEARANCE REPORT
Project Address:
Lot:
Block:
Development Name:
Quality Assurance Agency:
Owner/Agent:
Owner/Agent Signature:
Date:
CCBD Inspector Initials
Date:
INSTALLATION INSPECTION SUMMARY
INSPECTION ITEM
RESULTS
INSPECTION ITEM
RESULTS
CCBD Plan Approval Date:
Quantity of Rods/Bolts Installed:
CCBD Plan Sheet & Detail
Hole Depth & Diameter:
Mechanical Product Name:
Anchor Diameter, Type & Length:
Evaluation Report No. & Date:
Anchor Embedment Depth:
Concrete Type and Strength
Anchor Spacing
Concrete Thickness
Anchor Edge Distance
Tightening Torque for Each Bolt
Hole Cleaning Procedure
LOCATIONS OF ROD/BOLT & ADDITIONAL INSPECTION INFORMATION
I hereby acknowledge that I have reviewed the approved plans,
ENGINEER STAMP HERE
applicable evaluation report, and manufacturers’ installation
instructions. I inspected the products and observed the product
installation. The anchor installation has been verified to be in
accordance with the manufacturer’s published instructions, the above
referenced evaluation report and the Clark County approved plans.
SPECIAL INSPECTOR (PRINTED)
SPECIAL INSPECTOR (SIGNATURE)
DATE
Return completed certification to Clark County Building Department
Form 851
2/27/2017
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