HomeMy WebLinkAbout2003-HVAC Compliance Statement Buiidings, HVAC, Compliance Statement
This form is required to be submitted by the supervising professional (archited, engineer, HVAC designer or electncal
designer) observing construction of projects within buildings with total areas 50,000 cubic feet or greater and bleachers
(Comm 50.1 a/Comm 61.50). Failure to submit this fortn may resutt in penalties as specified in Comm 50.26/Comm 61.23
and/orlocalordinances.
General Instructions: Prior to the initial occupancy of new buildings or additions and the final occupancy of
altered existing buildings, submit this completed and signed form to:
• The municipal buiiding inspection office and
• Safery and Buildings, 1054'I N Ranch Road Hayward,W a 54843
P≤rsa T' in���Tanc:i;'ov �rovide may be used for secondary purposes[Privacy Law s. 15.04 (9)(yn,)]. '� �" `�
1. F'ROJECT INFORMATION: Please fili in the following with info.�i a.�:.n f�om your pia r����`���
V+'
Transadion ID Number 807599 N�ip .
168175 ' ��"'
Site Number ��-P
280 W35TQ Avenue ����/t9/�rt,'aRTi�f�r 7
Site location (number& street) ��� y •
C� City 0 Village ❑ Town of oshkosh County of winn ��
2 PURPOSE OF THIS STATEMENT: (Check Box A, B, C, ar D to indieate purpose and complete an ��r
applicable boxes and infortnation. Attach additianal pages if necessary.)
Check thase which apply: ❑ Building Object ID# _ �I HVAC Objed ID# 88091 5
❑ Lighting Objed IID#
❑ Partial Completion
Description of Portion Completed
A) ❑ Statement of Substantial Complianr.e
To the best of my knowledge, belief, and I:�ased on onsite observation, construcCon of the following building and/or HVAC
Rems applicable W this project have been completed in substantial compliance with the approved plans and
specifications.
� O BUILDINGIIIGHTING ITEMS
� 1. StruUwal syalam includin9 wbmdql and erac:�on of all buiWky componenb 10. Exterior lightin9 8 control raqunmenb
(wasea.Precast.matal huYding.etc.) 11. IMerior Ifghtlnp 8 eordrd requiremanta
2 Fire protedion systema(aprinlden,alartns,smoke detedors)designad, 12 AU eonditlons of Ilghting plan approval
inafalbd.and tes4ed(InGudln9 fo�+'ab Ilw'�on badt 1bw devices)by and appNcade vartances
appropAatey iegbterad potaadonals
3. Shart a�M dairv�ay mdoars
4. Exds indudnp exR and dtactbrnl6qhts �,
5. Flro-�e�idiva conatructlon,enebauro of hazarda,tlre we0s,hbekd doora,dass � HVAC ITEMS ��,.
of co�rotrt�ctlon.tts atoPP�Ps��°^s faC8ltlea 1. HVAC�ya0em h�du�rg Mal test
H. Sanilatbn ayetem(Milels,ainim. Idn9 � 2 qp�nditlons of HVAC plan approval and
7. Bartfar-hea indu�tg Comm 78 eNvaOors and Iil� �������s
8. Energy amebpe raquYameMs
9. Ail mndRiorro ot bu�oD Dmn appiowl anc appkatk var'srnxs �
7he followiny IEems an not in compliance and must be add►essad: �AC Te sting And Balancing
!
Report
� g) p Statennnt ot Noncomplianu
Due to the followiny Ifated vidations,this project is not ready Tor occupan�y:
f
r,:,, '. '.C)< Cl,:'�ke�ginreisirog Pr�U�sional WilLdrawn Fnom Projeet (Uae A or�above�ta i�cate pro�rct atuYhia ae ui ttw��ste.) . ,
D) ❑ ProjeetAbandoeed
3. SUPERVISING PROFESSIONAL SIGNATURE FOR:
❑ Buil�ng � HVAC O Lighdny MIchael Leberfin� Date I� •
Nam�(plessa pi�rt or hPa) " ' ' � / �
�K �I
Phone number
(92�)739-73���er ID# 649474 siynature' - �1 -"'�
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