HomeMy WebLinkAboutCOMPLIANCE STATEMENT
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040~
Buildings, HVAC, Compliance Statement .:::rq",Sot~~ ~:~-€-1
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 50,000 cubic feet or greater and bleachers
(Comm 50.101Comm 61.50). Failure to submit this form may result in penalties as specified in Comm 5O.261Comm
61.23 and/or local ordinances. - i
Generallnstructions: Prior to the initial ~pancy of new buildings or additions and H ~~\Y4íE' D I
. altered existing buildings, submit this completed and signed form to: æ;,;'\::L.,..-,- V, I
. The municipal building inspection office and . i
. Safety and Buildings, 10541N Ranch Road Hayward, Wi. 5484S\N 1 02006 j
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 elflvlliM;ØVirtl&rT OF
Transaction 10 Number "T r, 4 ;v:; d. - NITV DEVELOPMENT
Site Number ~'1Dd.hq'
Site location (number & street) q~3 Dr-e~(J"S\--
~City C Village C Town of Osh/tr,d., County of ft-?ì.,t'I~baj()
2. PURPOSE OF THIS STATEMENT: (Check Box A. e, C, or D to indicate purpose and complete any-other
applicable boxes and information. Attach additional pages if necessary.) -
Check those which apply: % euildingObject ID # c:r Y 00 7 ç [:J HVAC Object ID #
[:J Ughting Object ID #
[:J Partial Completion
Description of Portion Completed .
AI or! Statement of Substantial Compliance " .
~e best of my knowledge, belief, and based 01'\ onsite observation, construction of the following building and/or
HVAC items applicable to this project have been completed in substantial compliance with the approved plans and
specifications.
C BUILDINGlUGHTlNG ITEMS
1. Struclilral system Ù1CWding submittal and erection 01 all building CQI1 IOIIeIdS
(truss., -~ metal building, eIC.)
2. Foe prcf8oIion ~ (8 11Ïn1don1, 1Iianna. """*" -.ra) dealgned. ilia-.
and tested (including fOlW8ld flow on back flow devices) by II IpR>priateIy registered
prot...ionaIa -
3. Shalt 8IId ataIrway encIœU18
4. EXia including 8ICit 8IId directionallighla
5. FirHeaialNe conatruction, encIœure of hIlaRIa, lint walla, labeled dears, clan 01
construction, lire 8ICIpped ~
6. S8niIaIicq system ('*'", ainka, drinking facIiIieI)
7. Barrier.free Including Cømm 18 eIovaIars 8IId Iifta
8. Energy 8IMIIcpe requiÆments
9. All concüIiana 01 building pIIM1 approval and applicable variance8 ,
The following item. ant not In compliance and muat be adclreaaec:l:
10. Exterior IIghlirig & ccntrcI requlremenla
11. Intsricr lighting & ccntrcI req'"'-'ta
12. All conditions 01 lighting pIÒn --'
and applicable variances
C HYAC rrEMS
1. HVAC system including finalteol
2. AI condilic(la of HVAC pIIM1--, 8IId
applicable variances
- B) [:J Statement of Noncompliance -
Due 10 the following listed violations, thit! project is not ready for occupancy:
C) [:J SupelVislng Professional Withdrawn From Project (Use A or B above to indicate project status as of this date.)
D) [J Project Abandoned .
3. SUPERVISING PROFESSIONAL SIGNA1:URE FOR:
C Building C HVAC C Ughting /vi
NIIne (please print or type!
Phone numberq1f)1~1 I:) L Customer 10# 'd:5 cr 3, h