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Home My WebLink AboutCertificate of Occupancy CITY HALL Inspeption Services Div 215 Church Avenue PO Box 1130 ~ Oshkosh WI ~ 54903-1130 OJHKOJH ON THE WAm City of Oshkosh Approved: Issued: 11/1/05 11/2/05 Midwest General Contractors Inc. 100 N. Westhaven Drive Oshkosh, Wisconsin 54904 CERTIFICATE OF OCCUPANCY An Occupancy Permit is hereby granted for the new 4 unit condo located at 3125 White Tail Lane, Oshkosh, Wisconsin 54904 as described in Building Permit Application number(s) 112354. This building is to be used only as a multi-family residence and is located in the R-3, Multiple Dwelling District. LIMITATIONS: Maximum persons and/or living units: One family per living unit CONDITIONS: 1) Final grading must be done in accordance with the approved subdivision drainage plan. This plan is on file in the public works office, 3rd floor of City Hall. 2) Erosion control measures must be maintained until the lawn is established. Note: Final grade must be a minimum of 6" below all siding. NOTE: 1) Copies of inspection results are available upon request in room 205, City Hall. 2) Future permits may be required for additional work to your property. A new Certificate of Occupancy shall be required prior to occupancy, should additional building(s) be erected, or should any buildings mentioned above be altered or moved. The use of land, or buildings, shall not be changed until a Certificate of Occupancy is issued for that occupancy. All conditions noted above must be complied with in order for this certificate to be valid. ¡J¡ dJt ~ Building Systems Inspector JobAddresa 3125WHITETAILLN Owner WAUKAU LLC Building Permit Work Card Permit Number 0112354 Create Date 1/13/05 Contractor MIDWEST GENERAL CONTRACTORS INC Category 130 - New Multi-Family Type . Building Zoning 0 Sign 0 Canopy 0 Fence 0 Raze Plan N8-02-0105 Class of Const: Size Value $340,000.00 Stories 1 Height ~ Ft. 0 Floating Slab 0 Post 5647 Sq. Ft. Garage 1920 Sq. Ft. ~ n Projection I Canopies 0 Signs Unfinished/Basement 0 Sq. Finished/Living -Ft. Rooms 0 Bedrooms ~ Baths Foundation. Poured Concrete 0 Concrete Block 0 Pier 0 Treated Wood 0 Other Occupany Permit Required Flood Plain No Height Permit Not Required Park Dedication Required # Dwelling Units ~ # Structures Use/Nature COMM/4-Unlt Condo- 2 bedroom units with 2 car attached garages. of Work HVAC Contr BREWER HEATING Electric Contr CUMINGS ELECTRIC INC Plumbing Contr WATTERS PLUMBING Inspections: Date ~-'------- Type Final Inspector Nicole Krahn approved r-'"' DatelTime requested: 10/31/05 03:31 PM Access: ~ants to be present. Ready DatelTime: 10/31/05 03:31 PM Requested By: MIDWEST HOMES OF WI-Jay 0 Reinspect Fee 0 Fee Waived Notice Type: Phone Number: 420-5878 D Reinspect Fee Paid - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - --- - - - - - -- - - - - - - - -- --- - --- - - ----- - - - - ---- --- Page 3 of 3 Job Address 3125 WHITE TAIL LN Owner WAUKAU LLC Building Permit Work Card Permit Number 0112354 Create Date 1/13/05 Contractor MIDWEST GENERAL CONTRACTORS INC Category 130 - New-Multi-Family Type. Building Zoning 0 Sign 0 Canopy 0 Fence 0 Raze Plan N8-02-0105 $340,000.00 Class of Cons!: Size Value Stories 1 Foundation. Poured Concrete 0 Concrete Block Height ~ Fi. 0 Floating Slab 0 Post 5647 Sq. Ft. Garage 1920 Sq. Ft. ~ n Projection I Canopies 0 Signs Unfinished/Basement 0 Sq. Finished/Living -Ft. Rooms ~ Bedrooms ~ Baths 0 Pier 0 Treated Wood 0 Other Occupany Permit Required Flood Plain No Height Permit Not Required Park Dedication Required # Dwelling Units ~ # Structures Use/Nature of Work OMM/4-Unil Condo- 2 bedroom units with 2 car attached garages. HVAC Contr BREWER HEATING Electric Contr CUMiNGS ELECTRIC INC Plumbing Contr WATTERS PLUMBING Inspections: Date ~-"---- Type Rough In r"'"'~"" DatelTime requested: 7/20/05 07:23 AM -- Access: Inspector John Zarate approved Notice Type: Phone Number: 420-5870 JAY 10PEN 7-5 Ready DatelTime: 7/20/05 07:23 AM Requested By: MIDWEST GENERAL CONTRACTORS INC 0 Reinspect Fee 0 Fee Waived D Reinspect Fee Paid ----------------------------------------------------------.---------------------------------- Date 7/25/05 -- Type Insulation Inspector John Zarate no time Request LIne (rec'd Friday 7/22/05 4:49 PM) DatelTime requested: Access: 10pen 7-5 7/25/05 07:00 AM Notice Type: Phone Number: 420-5878 Ready DatelTime: 7/25/05 07:00 AM Requested By: MIDWEST GENERAL CONTRACTORS INC-Jay 0 Reinspect Fee 0 Fee Waived D Reinspect Fee Paid - - - - - - - - - - - - - - - --- - - - - - - - ---- - --- - - - -- - - - - - - ---- - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - - - -"- - - - - -- Page 2 of3 Job Address 3125 WHITE TAIL LN Owner WAUKAU LLC Building Permit Work Card Permit Number 0112354 Create Date 1/13/05 Contractor MIOWEST GENERAL CONTRACTORS INC Category 130 - New Multi-Family Type. Building 0 Sign 0 Canopy 0 Fence 0 Raze Plan N8-02-0105 Zoning Class of Const: Size Value $340,000.00 Unfinished/BaSement ~ ~~. Finished/Living 5647 Sq. Ft. Rooms ~ Bedrooms ~ Baths ----.!1 Garage ~ Sq. Ft. n Projection I Stories Height ----.!1 Ft. 0 Floating Slab 0 Post Canopies ----.!1 Signs Foundation. Poured Concrete 0 Concrete Block 0 Pier 0 Treated Wood 0 Other Occupany Permit Required Flood Plain No Height Permit Not Required Park Dedication Required # Dwelling Units ~ # Structures Use/Nature COMM/4-Unit Condo- 2 bedroom units with 2 car attached garages. ofWork HVAC Contr BREWER HEATING Electric Contr CUMINGS ELECTRIC INC Plumbing Contr WATTERS PLUMBING Inspections: Date ~ -'---- Type Footings r~o ",oom ,-,-, ">,,æ~ Date/Time requested: 5/6/05 03:24 PM Access: Inspector Nicole Krahn no time Notice Type: Phone Number: MIKE OR TOM 231-1667 Ready Date/Time: 5/9/05 13:30 PM Requested By: JOHN SKOTZKE CONCRETE CONST 0 Reinspect Fee 0 Fee Waived D Reinspect Fee Paid --------------------------------------------------------------------------------------------- Date ~ -'---- Type Foundation Backfill Inspector Nicole Krahn EQ,UEST LINE NOTE: The foundation was already backfilled. not approved Date/Time requested: Access: 5/12/05 12:07 PM Notice Type: Phone Number: JAY 420-5878 Ready Date/Time: 5/13/05 12:07 PM Requested By: MIDWEST GENERAL CONTRACTORS INC 0 Reinspect Fee 0 Fee Waived D Reinspect Fee Paid ---- - - - - - - - - - - - - ----- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - --- - - -- - - - - - - - - - - -- Page 1 of3 Electric Permit Work Card Job Address 3125 WHITE TAIL LN Owner WAUKAU LLC Permit Number 115161 Create Date 01/18/2005 Contractor CUMINGS ELECTRIC INC Category 631 - Residential-New Multi-Family Wiring Service ~. Volts 120/240 0 ChangeO Temp 0 NIA I Type 0 Overhead Circuits 50 . Underground 0 N/A Fixtures ----IQ Amps 400 Switches 100 Receptacles ~ Fee $204.00 0 Value $12,000.00 Appliances Use/Nature of Work OMMI Wiring for 4-Unit Condo- 2 bedroom units with 2 car attached garages. Inspections: Date 07/21/2005 Type Re Rough In Inspector Kevin Benner approved DatelTime requested: 07/20/2005 00:00 PM Access: Notice Type: Phone Number: Ready DatelTime: 07/21/2005 00:00 AM Requested by: 0 Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid CUMiNGS ELECTRIC INC Wes -----------------------------------------------------------------------------------. Date 09/22/2005 Type Final Inspector Adam Krause approved DatelTime requested: 09/22/2005 12:25 PM Access: Notice Type: Phone Number: Ready DatelTime: 09/22/2005 12:25 PM Requested by: Jan w/ Cummings 0 Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid -----------------------------------------------------------------------------------. Electric Permit Work Card Job Address 3125 WHITE.TAIL LN OWner WAUKAU LLC Permit Number 115161 Create Date 01/18/2005 Contractor CUMINGS ELECTRIC INC Category 631 - Residential.New Multi-Family Wiring Ó ChangeO Temp 0 N/A Service p New Volts 120/240 Amps ~ Circuits I Type 0 Overhead 50 . Underground 0 NIA Fixtures 70 Receptacles 160 Value $12,000.00 Switches ~ Fee $204.00 0 Appliances Use/Nature ofWork OMM/ Wiring for 4.Unit Condo- 2 bedroom units with 2 car attached garages. Inspections: Date 07/14/2005 Type Service Inspector Kevin Benner approved Request Line Faxed to WPS 711515, Mailed 7/25/5 DatelTime requested: 07/14/2005 08:13 AM Access: Notice Type: Phone Number: Ready DatelTime: 07/14/200508:13 AM Requested by: 0 Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid CUMINGS ELECTRIC INC-Jan -----------------------------------------------------------------------------------. Type Rough In Inspector Kevin Benner not approved Date 07/20/2005 REQUEST LINE / READY 7/20 LATE PM The electrical panels were not installed The exterior receptacle boxes were not wired Approved to insulate on 7/21/5 DatelTime requested: 07/19/2005 10:20 AM Access: Notice Type: Phone Number: NOT GIVEN Ready Date/Time: 07/20/2005: PM Requested by: 0 Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid CUMINGS ELECTRIC INC -----------------------------------------------------------------------------------. Job Address 3125 WHITE TAIL LN HV AC Permit Work Card Permit Number 114460 Create Cate 01/18/2005 Owner WAUKAU LLC Contractor BREWER HEATING Category 502 - Residential-Both Plan Fuel ~ IT2C:J 1,11 Electric I ~ ~ Value $18,000.00 System [7] New n Replace n Other I ~ Forced Air I U Radiant I U Steam I ~ AIC I U Vent I U Electric I U HotWater I U Suppl. I U Con. Burner I Chimney Type KJ Chimney A 0 ChimneyB . Direct Vent 0 Not Applicable Heat Loss . As Approved C) Existing 0 Not Applicable I Value BTU Rate . As Per Plan 0 Variabie 0 Other I Value Use/Nature OMM/ HVAC system as per State Transaction ID # 1125586 4-Unit Condo- 2 bedroom units with 2 car of Work ~ttached garages. Inspections: Date 11/1/05 Type Final Inspector Nicoie Krahn approved CatelTime requested: 11/01/2005 11:59AM Notice Type: Phone Number: Access: Ready CatelTime: 11/01/2005 11 :59 AM Requested By: 0 Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid - - - - - - - ---- - - - - - - - - - - -- - - - - --- - - - - - - - - -- ------- - - - - - - - - - - - - ---- -- - - - - - - -- ---- - - - - - - - - - - - - --- , Plumbing Permit Work Card - Job Address 3125 WHiTE"TAIL LN Permit Number 114100 Create Date 05/16/2005 Owner WAUKAU LLC Contractor WATTERS PLUMBING Category 440 - Industrial-Interior Plan Value $17.940.00 Bathtub 4 Shower ~ Water Softner 0 Wait.St. ~ Shamp Sink ~ Coffee Maker ~ Whirlpool ~ Floor Drain ~ Local Waste 0 Ice Chest 0 FlrlWst Sink ~ Int Grease Trap 0 Lavatory 8 Lndry Tray ~ Clothes Wshr 4 Exam Sink 0 Catch Basin ~ Ext Grease Trap ~ Toilet 8 Disposal ~ Bidet ~ Sculry Sink ~ Wash Ftn ~ RPZ Valve 0 Res. Sink 4 Dishwasher ~ Beer Tap 0 Hand Sink ~ Urinal ~ Eye Wash Statn ~ Bar Sink ~ Sump Pump ~ Lab Sink ~ Plaster Sink ~ Standp Rec ~ Wtr Sewer Mtrs ~ Water Heater 4 Classrm Sink ~ Sterilizer 0 Surgeons Sink 0 Ice Maker ~ Deduct Meters ~ Site Drain ~ Breakrm Sink ~ DipWell ~ F Prep Sink ~ Gar Drain ~ Wtr Usage Mtrs 0 Roof Drain ~ Ejector/Grind ~ Drink Ftn 0 Serv Sink 0 Soda Disp ~ Misc. ~ Fixtures Use/Nature I of Work Interior plumbing for new 4-Unit Apartment (Ck#59455) Size Material Type # Conn.Type Sanitary Sewer 0 0 0 0 0 Storm Sewer 0 0 0 0 0 Water Service 0 0 0 0 0 Date 11/1/05 Type Final Inspector Nicole Krahn approved r- .,- DatelTime requested: 9/20/05 08:55 AM Notice Type: Access: ~ay 420-5878 Telephone Number: 920-733-8125 Ready DatelTime: 9/20/05 09:00 AM Requested By: WATTERS PLUMBING-Jamie 0 Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid --------------------------------------------------------------------------------------------------------- Job Address 3125 WHITE TAIL LN Owner WAUKAU LLC Category 440 - Industrial-Interior Bathtub 4 Shower Whirlpool ~ Floor Drain Lavatory 8 LndryTray Toilet 8 Disposal Res. Sink 4 Dishwasher Bar Sink ~ Sump Pump Water Heater 4 Classrm Sink Site Drain ~ Breakrm Sink Roof Drain ~ Ejector/Grind Misc. 0 Fixtures Use/Nature of Work 4 4 0 4 4 ~ ~ ~ 0 Plumbing Permit Work Card Permit Number 114100 Water Softner Local Waste Clothes Wshr Bidet Beer Tap Lab Sink Sterilizer Dip Well Drink Ftn Interior plumbing for new 4-Unit Apartment (Ck#59455) Size Sanitary Sewer Storm Sewer Water Service Date 7/15/05 Type Rough In Inspector Rich Wood r"~'. Material Type - Contractor Plan WATTERS PLUMBING 0 0 4 0 0 0 0 0 0 Wait.St. Ice Chest Exam Sink 0 ~ 0 ~ ~ ~ 0 ~ ~ Shamp Sink 0 FlrlWst Sink ~ Catch Basin 0 Wash Ftn ~ Urinal ~ Standp Rec ~ Ice Maker 4 Gar Drain ~ Soda Disp ~ approved Create Date 05/16/2005 Value Coffee Maker Int Grease Trap Ext Grease Trap RPZ Valve Eye Wash Statn Wtr Sewer Mtrs Deduct Meters Wtr Usage Mtrs $17.940.00 ~ ~ ~ 0 ~ ~ ~ ~ DatelTime requested: 7/14/05 01:29 PM Access: Notice Type: Sculry Sink Hand Sink Plaster Sink Surgeons Sink F Prep Sink Serv Sink # 0 0 0 0 0 Conn.Type Telephone Number: 733-8125 0 0 0 0 0 0 0 0 0 0 Ready DatelTime: 7/14/05 03:00 PM Requested By: WATTERS PLUMBING-Jamie 0 Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid --------------------------------------------------------------------------------------------------------- Job Address 3125 WHITE TAIL LN Owner WAUKAU LLC Category 440 - Industrial-Interior Bathtub ~ Whirlpool ~ Lavatory ~ Toilet ~ Res. Sink ~ Bar Sink ~ Water Heater ~ Site Drain ~ Roof Drain ~ Misc. ~ Fixtures Plumbing Permit Work Card Permit Number 114100 Create Date 05/16/2005 Contractor WATTERS PLUMBING Plan Value $17,940.00 Shower ~ Water Softner 0 Wait. St. ~ Shamp Sink 0 0 Floor Drain ~ Local Waste 0 Ice Chest ~ FlrlWst Sink ~ Int Grease Trap ~ Lndry Tray ~ Clothes Wshr 4 Exam Sink ~ Catch Basin 0 Ext Grease Trap ~ Disposal ~ Bidet 0 Sculry Sink ~ Wash Ftn 0 RPZ Valve 0 Dishwasher ~ BeerTap 0 Hand Sink ~ Urinal ~ ~ Sump Pump ~ Lab Sink 0 Plaster Sink ~ Standp Rec ~ 0 Classrm Sink ~ Sterilizer 0 Surgeons Sink ~ Ice Maker ~ ~ Breakrm Sink ~ DipWell 0 F Prep Sink ~ 0 0 Ejector/Grind ~ Drink Ftn 0 Serv Sink ~ 0 Coffee Maker Gar Drain Soda Disp Eye Wash Statn Wtr Sewer Mtrs Deduct Meters Wtr Usage Mtrs Use/Nature II of Work .1 Interior piumbing for new 4-Unit Apartment (Ck#59455) I Type # 0 0 0 0 0 0 0 0 0 0 Size Material Conn.Type Sanitary Sewer Storm Sewer Water Service Type Underground Inspector Rich Wood approved Date 5/18/05 r~o ~OO,,' DatelTime requested: 5/18/05 09:14 AM Notice Type: Telephone Number: JAMIE 733-8125 Access: Ready DatelTime: 5/18/05 01:00 PM Requested By: WATTERS PLUMBING 0 Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid ------------------------------------------- ---------------------------------- ----- --- -------------------- e OSHKOSH ON THE WATER Job Address 3125 WHITE TAIL LN CITY OF OSHKOSH No 112354 BUILDING PERMIT - APPLICATION AND RECORD Owner WAUKAU LLC Create Date 01/13/2005 Designer Contractor MIDWEST GENERAL CONTRACTORS INC Category 130 - New Multi-Family Plan N8-02-0105 Type 18 Building 0 Sign 0 Canopy 0 Fence 0 Raze Class of Const: Rooms 0 Height 0 Ft. Bedrooms 0 Stories 1 Baths 0 Size Zoning Unfinished/Basement 0 Sq.Ft. 5647 Sq.Ft. U Projection 1 Finished/Living Canopies 0 Garage ~ Sq. Ft. Signs 0 Foundation 8 Poured Concrete 0 Floating Slab 0 Concrete Block 0 Post 0 Pier 0 Treated Wood 0 Other Occupancy Permit Required Flood Plain No Height Permit Not Required Park Dedication Required # Dwelling Units 4 # Structures COMM/ 4-Unit Condo- 2 bedroom units with 2 car attached garages. Use/Nature of Work HVAC Contractor BREWER HEATING Plumbing Contractor WATTERS PLUMBING Electric Contractor CUMINGS ELECTRIC INC Fees: Valuation $340,000.00 Plan Approval $0.00 Permit Fee Paid $1,099.00 Park Dedication $660.00 Issued By: Date 01/18/2005 Final/O.P. 00/00/0000 U Permit Voided 1 Parcelld # In the performance of this work I agree to perform all work pursuant to rules governing the described construction. While the City of Oshkosh has no authority to enforce easement restrictions of which it is not a party, if you perform the work described in this permit application within an easement, the City strongly urges the permit applicant to contact the easement holder(s) and to secure any necessary approvals before starting such activity. Signature Date Address 100 N WESTHAVEN DR Agent/Owner OSHKOSH WI 54904 - 0000 Telephone Number 426-2008 To schedule inspections please call the Inspection Request line at 236-5128 noting the Address, Permit Number, Type of Inspection (i.e. Footing, Service, Final, etc.), Access into Building if Secure (how do we gain entry), your Name and Phone Number. Unless specified otherwise, we will assume the project is ready at the time the request is received. Work may continue if the inspection is not performed within two business days from the time the project is ready. Sep 29 05 10:09a DON HAANEN 920-497-5007 p.1 Buildings, HVAC Compliance Statement SBD-9720 This form is required to be submitted by the supervising professional (architect, engineer, HVAC designer or electrical designer) observing construction of projects within buildings with total areas exceeding 50,000 cubic feet or greater and bleachers (Comm 50.1 O/Comm 61.50). Failure to submit this fonn may result in penalties as specified in Comm 50.26/Comm 61.23 and/or local ordinances. 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 building inspection office and . Safety and Buildings, 10541 N Ranch Road, Hayward, WI 54843 Personal information you provide may be used for secondary purposes [Privacy Law. s. 15.04 (1)(m)]. 1. PROJECT INFORMATION: Please fill in the following with information from your plan approval letter. Transaction 10 Number 1079563 Site Number 669115 Site location (number & street) 3125 WHITETALE 0 City 0 Village 0 Town Of OSHKOSH County of WINNEBAGO 2. PURPOSE OF THIS STATEMENT: (Check Box A, B, C, or D to indicate purpose and complete any other applicable boxes and information. Attach additional pages if necessary). Check those which apply: 0 Building Object ID# 991637 0 Lighting Object ID# 0 Partial Completion 0 HVAC Object 10# Description of Portion Completed A) 0 Statement of Substantial Compliance To the best of my knowledge. belief. and based on onsile observation, construction of the following building and/or HVAC items applK:able to this project have been completed in substantial compliance with the approved plans and specifications. 0 BUILDING/LIGHTING ITEMS 1. Slructural system including submittal and erection of all building components (trusses. precast. metal building. etc.) 2. Fire protection systems (sprinklers, alarms. smoke detectors) designed. installed. and tested (including fofWard flow on back flOw devices) by appropriately registered professionals. 3. Shaft and stahway enclosure 4. Exits including exit and directional lights 5. Fire-resistive construction. enclosure of hazards. fire walls. labeled doors, class of construction, fire stopped penetrations 6. Sanitation system (toilets, sinks, drinking facilities) 7. Barrier-free Including Comm 18 elevators end lifts 8. Energy envelope requiremenis 9. All conditions of building plan approval and applicable variances The fallowing items are not in compliance and must be addressed: 10. Exterior lighting & control requirements 11. Interior lighting & control requirements 12. All conditions of lighting plan approval and applicable variances 0 HVAC ITEMS 1. HVAC system including final test 2. All conditions of HVAC plan approval and applicable variances B) 0 Statement of Noncompliance Due to the following listed violations, this project is not ready for occupancy: C) 0 Supervising Professional Withdrawn From Project (Use A or B above to indicate project status as of this date.) D) 0 Project Abandoned 3. SUPERVISING PROFESSIONAL SIGNATURE FOR: 0 Building 0 HVAC 0 Lighting DON HAANEN Name (please print or type) Customer 10# 649536 Signature Phone # 920-497-5007 SBD-9nO (R.OI/200') 9/26/2005 Buildings, HVAC, Compliance :statemem This form is requited to be sl.Ibmin"ð by the supetV~in9 professional (architect, engine...., HVAC c!esignef or electrical cosigner) oosarvi"g çonSlrwçliOl1 of projects wit";n Ouildings with lotal areas 50.000 cubic feel or greater and bleacl18rS (Oomlll 50. 10/Comm 61.50). Failure to suomìt this form may resllit in pvnalties as specified in Comm SO.26IComm 61.23 andlor IoC8I ordinances. General InstructiOns: PrIOr to the initial occupancy of new buildings Of additions and the final occupancy of altered existing buildings. submit this completed and signed form to: . The municipal building inspec:lion office W . Safety and Buildings. 10541N Ranch Road Hayward. Wi. 54843 Pe,*,n¡¡ inIormatio" you ptOvid8 may De yscd lor secon""'Y PWr)Oses [Privacy Law, $. 15.04 (1 )(m)]. . 1- PROJECT INFORMATION: Please fill in the following with information from your plan approval letter. Transaction 10 Number 112S.s~" . Site Number 6'-"11 ~ Site)øe2tion (number & street) [!('City 0 Village IJ Town of (1s::~~ h county of hi ~~ð 2. PURPOSE OF THIS STATEMENT: (Chec~ aox A. a, C. or 0 to inðicate purpose 3nð complete any other applICable boxes and infonne\Îon. Attach ade!itlonal pages if necessery.) -j:/I'I' ~ Chec~thosewhichapply: OBuí(¡ngObjectID# CHVACObjecIID# /6/ :1<;.;2..4 lðOlol() 0 Lighting Object 10 Ii 1.)",1<;./..:,1 0 Partial completion / Description 01 Portion Completed A) 13' Statement of Substantial Compliance "0 the best of my knoWleGge. belief. and b.seo on onsire observation. constn,¡çlÌon 01 \lie following building ..nC/o' HVAC ItemS apolicaolo 10 this project have been eomØlOlea In sut>s1anlial compliance witn the approved plans and SpeCifICations. I:] ISUILDINGIUGHTING l,.eM1i ,. S,rue""" System induøinQ ,ubtI\it!ala"" e,ec;liOl1 of a" Du~lng comoo"o,"S (INSMS. Oro<:oo'. "",18' bul'ding. tIC.) 2. Fi,. ",,*~0<1 SY"IJ!mS (sprink""". alarmS, sm"". ""'oC:P'O) c.sI9n,",. ¡n"",lled. and ...,.., ~ncluCi!IÇ """"'" ft"" D" bOe. ftow ..vices)!Iy 'OI>rwnatel~ ~i.t.'e<I o""""OM" 3. SNl~ 004 .,.',-y enelOSulll 4. EJó.. ir<:lwling eoit O"C OIteCtialal 'ight> 5. F,....-Isli"" canS"\K:lion. enClOSUre 01 hazo",s. filii ..ails. 1aO."'" _ro. "... 01 """"truc:tioo. fi~ ."'0004 00"""-- 6. Sen",,*," system ("",""'. Slnlel. Glinking 18clII'.I) 7. 8O,ner-fr.. il'duding Co",", '8 -""" and I;n. 8. Energy envelope re~,"...m,",,'" !I. AU """,nOOn, of þ,¡ilding 0'0" oØ(lroval ond ODo~..bl. .."»"- The feUowing items life nO( i" c;ompU~nee and mult be IcI<I~Sle(\: /). I) R.""'""f~ . B) CI Sl3tement of Noncompliance Cue!O 1M following listed ,",ola1ions. tIIis "",jed i> nOI ready for oceupancy: 10. !Om"c' lign""Ç & oon¡tO' !ØCu""",.n:s 1 '. ,"",riO' ign"!IÇ & <on"01 ,..;ui'.m.". 12. A" ooMi';""s 0: liÇ'""9 piOn .00'0'" an~ oPp;,..~i. van. noes C HVAC IT£I4S ,. HVAC >y,,- IndVc'n¡ """,.... 2. AA!:<""""OM 0' ~Ar; plan opproua' one "Opll..". .orian"'" ~.S'.t.t. ~ úJ~ .~ C) t:1 S<lpervising Professional Withdrawn From Project (Use A or B above !O indicate project s<atuS go; of this ca~.) 0) t:1 Projec:l Abandonee! 3. SUP~~~=i~~G ~~~~SS~O~~n:GN~ ~~...( Nom" (pl...e print or 'YOG) PhOno tlUmÞ<lt 7';...- 7o/Jt ~ Customer 10" C 'it ;;"'11/ J"1'!' Signature SSD-ono (".6i......oo~) 23 E'd -:- Cor, 6";4-<-",-s- Uþ¡! )on ~ TDT~L P.02 02S9-8i>oL-026 55aH a~~5~"':J e1S:01 so L1