HomeMy WebLinkAbout1995-Building Compliance Statement � Compliance Statement
This form is required to be submitted by the architect,engineer,or HVAC designer(supervising professional)
' observing construction of projectswithin buildingswith total volumes exceeding S0,000cubic feet and construttion
of antennas,towers and bleachers(ILHR 50.10). Failure to submit this form may result in penalties as specified in
ILHR 50.26 and/or local ordinances.
Generel Instructions: Prior to the initial occupancy of new buildings or additions and the final
occupancy of altered existing buildings,submitthis completed and signed form to:
The municipal building inspection office and
DILHR,.Safety and Buildings,P.O. Box 7969,Madison,WI 53707
1. PROJECTINFORMATION: (UsetheDlLHRormunicipalprojectlabel,ortypeorprinttheinformation.)
Owner Information Projed Information
C�=�i�LS���a:'k. '�TATE�fENT LtBE_ BuildingOccupanryChapter(s)BUse
Y HCT�JI{1��JFFI4C
� �QI�ARE U CC�F.P 7enantName (i any
A
Bui ing Laation num er 8 street
B 33C�0 ?/iEL}HLI�T C'RI"c
E !'"ya���H ❑City ❑Village ❑Town of
L. ga-'a9-04o'�-6
E�SJLG��C� COUIILy O .
E � Pian or nererence numoer � . Property I enti ¢ation Num r �
R Name and Registration Numher o t e Building Supervising Pro essiona Building Project� -
E
Name and Registration Number o the HVAC Supervising Pro essional HVAC Project f
2. PURPOSE OF THIS STATEMENT: (Check Box A B,or Cto indicate purpose and complete any other applicable
boxes and in�ormation. Attach additional pages if necessary.)
�� ❑ BuildingandHVAC �Bui�dingOnly ❑ HVACOnIy I!
❑ PartialCompletion
� Description of Portion Completed
A) ❑ Statement of Substantial Compliante
To the best of my knowledge,belief,and based on onsRe observation,construction of tM1e following building andlor HVAC items applicable to I
this projea have been completed in substantial compliancewiththe approved plans and specifiwtions.
�ILDINGITEMS pHVACITEM5 � �!
1. Structurel system including submittal and erection of all 1. HVAC system including final test
building componenu(trusses,precast,metal building,etc.) (ILHR 64.53)
2. Fire protection systems kprinklen,alarms,smoke detectors,
fire ext�nguishers)
3. Exiu including exit and directional lights 2. All conditions of HVAC plan approval
4. Shaft and stairway enclosures and applicable variances
5. Fire-resistive construction,enclosure of hazards,fire walls,
labeled doors,class of construdion
6. Sanitation system(toiiets,sinks,drinking facilities)
7. Barrier-free access and circulation
8. All conditions of building plan approval and applicable variances
The following items are not in compliance and must be addressed: �X-�-���/� v�Nn� NOr '�b'vE
/�CCO,QD/�c.U�' TO P�E'�/�.c1 ,a2Al.U/rt.��5 � S/�NAG� �5 �1/oT Q�aE G' Ov752L�
� P��G � ,�ET�Nno� C'G/P$ .G�T ,�QE�ENT @ lX�TaiO.E.
B) � Statement of Noncompliante
Due to the tollowing listed violations,this prqeR is not ready for occupancy:
C) ❑ Supervising Professional Withdrewn From Projed Date Withdrawn
(Use A or B above to mdica4e D�al�rtatus as of this dateJ �
SIGNATURES: � /, �
���� � r��� 6/s/9s' .
Building5upervisingProfessional Date HVACSupervisingProfessional Date
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