Structural observation form
City of Cypress
Community Development: Building Safety Division
5275 Orange Avenue
Cypress CA 90630
(714) 229-6730
Structural Observation
Report Form
Structural Observation means the visual observation of the structural system, for general conformance to the approved plans
and specification, at significant construction stages and at completion of the structural system. Structural observation does not
include or waive the responsibility for the inspections required by Section 110, 1701 or other sections of the code.
Report No. ________________________________
This report includes all construction work through : __________ day of ______ , 20_____ Page No. _________ of ___________
Project Address: Structural Observer of
Record (SOR):
SOR Phone Number:
Building Permit Number: Structural Observation
performed by:
Oberserver Professional
License/Reg. Number:
Observer Phone Number:
OBSERVED STRUCTURAL ELEMENTS AND THEIR CONNECTIONS
FOUNDATION WALL FRAMES FLOOR PORTION OBSERVED, IF NOT WHOLE
□Footing, Stem Walls □Concrete □Steel Moment Frame □Concrete
□Mat Foundation □Masonry □Steel Braced Frame □Steel Deck
□Caisson, Piles, Grade
Beams
□Wood □Concrete Moment
Frame
□Wood
□Retaining Foundation
Hillside Special Anchors
□Other: □Masonry Wall Frame □Other:
□Other: □Other:
OBSERVED DEFICIENCIES: _______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
I DECLARE THAT THE FOLLOWING STATEMENTS ARE TRUE TO THE BEST OF MY
KNOLEDGE:
1.) I AM THE ENGINEER OR ARCHITECT RETAINED BY THE OWNER TO BE IN
RESPONSIBLE CHARGE FOR THE STRUCTURAL OBSERVATION IN ACCO0RDANCE
WITH THE REQUIREMENTS OF THE CITY OF CYPRESS.
2.) I, OR ANOTHER ENGINEER OR ARCHITECT WHO I HAVE DESIGNATED ABOVE AND IS
UNDER MY RESPONSIBLE CHARGEM, HAS PERFORMED THE REQUIRED SITE VISITS
AT EACH SIGNIFICANT CONSTRUCTION STAGE TO VERIFY IF THE STRUCTURE IS IN
GENERAL CONFORMANCE WITH APPROVED PLANS AND SPECIFICATIONS.
3.) ALL DEFICIENCIES WHICH REMAIN TO BE CORRECTED HAVE BEEN INDICATED
ABOVE.
4.) I RECOMMEND THAT ACCEPTANCE OF THE STRUCTURAL SYSTEMS BY THE CITY OF
CYPRESS BE WITHHELD UNTIL ALL OBSERVED DEFICIENCIES ARE CORRECTED.
STAMP OF STRUCTURAL
OBSERVER OF RECORD:
Signature: DATE: