HomeMy WebLinkAboutAscension Health - DIS - 11242699Wisconsin Department of Safety and Professional Services Phone: 608-266-2112
Division of Industry Services Web: http://dsps.wi.gov
4822 Madison Yards Way Email: dsps@wisconsin.gov
PO Box 7302
Madison, WI 53707 Tony Evers, Governor
Dan Hereth, Secretary Designee
January 8, 2025
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES:
MUNICIPALITY:
CITY OF OSHKOSH
WINNEBAGO COUNTY
SITE:
ASCENSION HEALTH - MERCY MEDICAL CENTER
OSHKOSH
500 S OSKWOOD ROAD
OSHKOSH, WI 54904
SUBMITTAL INCLUDES:
SITE REQUIREMENTS
•A full size copy of the approved plans, specifications, and this letter shall be on-site during construction and open to inspection
by authorized representatives of the Department, which may include local inspectors. If plan index sheets were submitted in
lieu of additional full plan sets, a copy of this approval letter and index sheet shall be attached to plans that correspond with the
copy on file with the Department. If these plans were submitted in an electronic form, the designer is responsible to download,
print, and bind the full-size set of plans along with our approval letter. A Department electronic stamp and signature shall be on
the plans which are used at the job site for construction.
The following conditions shall be met during construction or installation and prior to occupancy or use:
KEY ITEMS:
1. SPS 382.20(13). The cross connection control assemblie indicated in the above Description box has been registered with the
Department. Each Device shall be tagged as per SPS 382.40(3)(d)3. Each device shall be tested and reported as per SPS
382.22(8). It is the responsibility of the owner to make sure each assembly is tested at installation and once a year thereafter.
2. SPS 382.20(8). The plumbing system shall be installed in accordance with the approved plans.
3. SPS 382.20(8). REVISIONS. All changes or modifications, which involve the provisions of chs. SPS 382 to 384, made to
plumbing plans and specifications, which have been granted approval under sub. (1), shall be submitted to the department or
agent municipality for examination. All changes and modifications shall be approved in writing by the department or agent
municipality prior to installation of the plumbing.
4.Electronic plans were submitted for this review. The plans included 2 pages, including an index.
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Code §§ SPS 381, 382,
and 384 only. The submittal has been CONDITIONALLY APPROVED.
Identification Numbers
Plan Review No.: PL-012500001-PRCCCAHCO
Application No.: DIS-112452699
Site ID No.: SIT-139126
Please refer to all identification numbers in each
correspondence with the Department.
KEVIN MASLANKA
2323 N ROEMER RD
APPLETON, WI 54911
DIS-112452699 Interior Cross Connection Control Assembly, Health Care - PL-012500010-PTOICCH
Type: Reduced pressure principle backflow preventer, Size: 3/4, Manufacturer: Watts, Model #: LF009M3QT, Specific Location:
463901, Serving: Alto-Shaam Combi-Oven
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. You are
responsible for complying with state and federal laws concerning construction near or on wetlands, lakes, and streams.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per Wis. Stat. § 145.06.
All permits required by the state or the local municipality shall be obtained prior to commencement of
construction/installation/operation. Pursuant to Wis. Stat. § 145.05(1), a city of the first, second, or third class shall supervise the
installation, alteration, and repair of plumbing within its jurisdiction. Should the project fall under jurisdiction of the Department,
please contact the DSPS inspector copied at the bottom of this letter.
In granting this approval, the Division of Industry Services reserves the right to require changes or additions, should conditions arise
making them necessary for code compliance. As per Wis. Stat. § 101.12(2), nothing in this review shall relieve the designer of the
responsibility for designing a safe building, structure, or component. The Division does not take responsibility for the design or
construction of the reviewed items.
Inquiries concerning this correspondence may be made to me at the contact information listed below, or at the address on this
letterhead.
Sincerely,
Shayne Kucko
Division of Industry Services
Phone: (715) 634-4804
Email: shayne.kucko@wisconsin.gov
cc:
DARRIN BENZ, PLUMBING PLAN REVIEWER, EMAIL: DARRIN.BENZ@WISCONSIN.GOV, OFFICE: 920-492-7726
DIANE BARTLETT, EMAIL: DBARTLETT@OSHKOSHWI.GOV, OFFICE: 920-236-5094
JOE SCHWEDA, OWNER
BRANDON CONRAD, INSTALLER