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Hilti. Outperform. Outlast. Version 02.2014 Adhesive Anchors Inspection Checklist for Concrete and Masonry Periodic special must be performed where required in accordance with Section 1705.1.1 and Table 1705.3 of the 2012 IBC, or Section 1704.15 of the 2009 IBC and Table 1704.4 or Section 1704.13 of the 2006 or 2003 IBC, whereby periodic special inspection is defined in Section 1702.1 of the IBC and this report. (See Structural Drawings for Inspection requirements) Project Name: _______________________________________________________________ Project Location: ____________________________________________________________ Weather: ______________________________ Air Temperature: ______________ (°F / °C) CODES ⃞ IBC 2003 ⃞ IBC 2006 ⃞ IBC 2009 ⃞ IBC 2012 Seismic Zone/ Seismic Design Category Adhesive Product Name/Manufacturer: _____________________________________________________________________________________ Lot No.: ________________________________________________________________________________________________________ ICC-ES Report No.: ______________________________________________________________________________________________ Adhesive expiration Date: ___/___/___ ⃞ Specified Dispenser ⃞ Specified Mixer Discard Initial Adhesive: _________ (# trigger pulls) Adhesive Tempature: ____________ (°F / °C) Gel Time: __________ Cure Time: __________ (per manufacturers installation instructions) Adhesive Element Type: ⃞ All-Thread ⃞ Internally Threaded ⃞ Torque-Controlled ⃞ Rebar ⃞ Other ______________ (Safeset TM only to be used with Hilti HIT-HY 200) Material: ⃞ Standard ⃞ Stainless Steel ⃞ High Strength Steel Grade/Coating: __________________ Length: __________________ (in/mm) Rod Diameter: ⃞ 3/8" ⃞ 1/2" ⃞ 5/8" ⃞ 3/4" ⃞ 7/8" ⃞ 1" ⃞ 1-1/4" ⃞ Other ______________ Rebar: ⃞ #3 ⃞ #4 ⃞ #5 ⃞ #6 ⃞ #7 ⃞ #8 ⃞ #9 ⃞ Other ______________ Base Material Base Material Type: ⃞ NW Concrete ⃞ LW Concrete ⃞ Brick ⃞ CMU ⃞ Other ______________ Base Material Strength: ⃞ 2000 psi ⃞ 3000 psi ⃞ 4000 psi ⃞ Other ______________ Base Material Thickness: ____________ (in/mm) Base Material Temperature: ____________ (°F / °C) Drilling & Hole Cleaning Drill Bit Diameter: _____________ (in/mm) Hole Depth: ________________ (in/mm) (core bit diameter, if approved) Drill Bit Type: ⃞ Carbide-Tip Drill Bit ⃞ Diamond Core Bit ⃞ Hollow Drill Bit ⃞ Other ______________ (ANSI B212.15-1994) (if appropriate and allowed) (Safeset TM only to be used with Hilti HIT-HY 200) Hole Condition: ⃞ Dry ⃞ Water Saturated ⃞ Water Filled ⃞ Under Water Hole Cleaning: ⃞ Compressed Air ⃞ Hand Pump ⃞ Wire Brush ⃞ Other ______________ Hole cleaning in accordance with manufacturers’ printed installation instructions: ⃞ Yes ⃞ No Application Anchor Application: (please check all that apply) ⃞ Tension ⃞ Shear ⃞ Overhead ⃞ Other______________ Anchor insertion: ⃞ Twisting motion ⃞ Annular gap filled with adhesive ⃞ Air Void Free Injection Anchor Spacing: _____________ (in/mm) Edge Distance: _______________ (in/mm) Embedment (h ef ): _____________ (in/mm) Installation Torque (if required): ___________ (ft-lb/Nm) Completed by: __________________________________________________ (Signature) Date:_____/_____/_____ __________________________________________________ (Print) Company:____________________________________ __________________________________________________ (Title) This form is for consideration for use by the responsible 3rd-party inspector.

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Page 1: Adhesive Anchors Inspection Checklist for Concrete ... - · PDF fileAdhesive Anchors Inspection Checklist for Concrete and Masonry ... IBC, or Section 1704.15 ... ⃞ IBC 2006 ⃞

Hilti. Outperform. Outlast.

Version 02.2014

Adhesive Anchors Inspection Checklist for Concrete and MasonryPeriodic special must be performed where required in accordance with Section 1705.1.1 and Table 1705.3 of the 2012 IBC, or Section 1704.15 of the 2009 IBC and Table 1704.4 or Section 1704.13 of the 2006 or 2003 IBC, whereby periodic special inspection is defined in Section 1702.1 of the IBC and this report. (See Structural Drawings for Inspection requirements)

Project Name: _______________________________________________________________

Project Location: ____________________________________________________________

Weather: ______________________________ Air Temperature: ______________ (°F / °C)

CODES⃞ IBC 2003⃞ IBC 2006⃞ IBC 2009⃞ IBC 2012

Seismic Zone/Seismic Design Category

Adhe

sive

Product Name/Manufacturer: _____________________________________________________________________________________Lot No.: ________________________________________________________________________________________________________ICC-ES Report No.: ______________________________________________________________________________________________Adhesive expiration Date: ___/___/___ ⃞ Specified Dispenser ⃞ Specified MixerDiscard Initial Adhesive: _________ (# trigger pulls)Adhesive Tempature: ____________ (°F / °C) Gel Time: __________ Cure Time: __________(per manufacturers installation instructions)

Adhe

sive

Ele

men

t Type: ⃞ All-Thread ⃞ Internally Threaded ⃞ Torque-Controlled ⃞ Rebar ⃞ Other ______________ (SafesetTM only to be used with Hilti HIT-HY 200)

Material: ⃞ Standard ⃞ Stainless Steel ⃞ High StrengthSteel Grade/Coating: __________________ Length: __________________ (in/mm)Rod Diameter: ⃞ 3/8" ⃞ 1/2" ⃞ 5/8" ⃞ 3/4" ⃞ 7/8" ⃞ 1" ⃞ 1-1/4" ⃞ Other ______________Rebar: ⃞ #3 ⃞ #4 ⃞ #5 ⃞ #6 ⃞ #7 ⃞ #8 ⃞ #9 ⃞ Other ______________

Base

Mat

eria

l Base Material Type: ⃞ NW Concrete ⃞ LW Concrete ⃞ Brick ⃞ CMU ⃞ Other ______________Base Material Strength: ⃞ 2000 psi ⃞ 3000 psi ⃞ 4000 psi ⃞ Other ______________Base Material Thickness: ____________ (in/mm)Base Material Temperature: ____________ (°F / °C)

Dril

ling

& H

ole

Cle

anin

g Drill Bit Diameter: _____________ (in/mm) Hole Depth: ________________ (in/mm)(core bit diameter, if approved)

Drill Bit Type: ⃞ Carbide-Tip Drill Bit ⃞ Diamond Core Bit ⃞ Hollow Drill Bit ⃞ Other ______________ (ANSI B212.15-1994) (if appropriate and allowed) (SafesetTM only to be used with Hilti HIT-HY 200)

Hole Condition: ⃞ Dry ⃞ Water Saturated ⃞ Water Filled ⃞ Under WaterHole Cleaning: ⃞ Compressed Air ⃞ Hand Pump ⃞ Wire Brush ⃞ Other ______________Hole cleaning in accordance with manufacturers’ printed installation instructions: ⃞ Yes ⃞ No

Appl

icat

ion Anchor Application: (please check all that apply) ⃞ Tension ⃞ Shear ⃞ Overhead ⃞ Other______________

Anchor insertion: ⃞ Twisting motion ⃞ Annular gap filled with adhesive ⃞ Air Void Free InjectionAnchor Spacing: _____________ (in/mm) Edge Distance: _______________ (in/mm)Embedment (hef): _____________ (in/mm) Installation Torque (if required): ___________ (ft-lb/Nm)

Completed by: __________________________________________________ (Signature) Date:_____/_____/_____

__________________________________________________ (Print) Company:____________________________________

__________________________________________________ (Title)

This form is for consideration for use by the responsible 3rd-party inspector.