HomeMy WebLinkAboutCOMPLIANCE STATEMENT BLDG/HVAC
Buildings,. HV AC, Compliance StatemR€ C IE
This form is required to be submitted by the supervising professional (architect, engineer, HVAC designer or e/ectnta
designer) observing construction of projects within buildings with total areas 50,000 cubic feet p(rgreajeFi ~bleachers
(Comm 50.10/Comm 61.50). Failure to submit this form may result in penalties as specified irt'Cbmm 5t>~.e!eomm
61.23 and/or local ordinances. D D. .;) ~. 1_
General Instructions: Prior to the initial occupancy of new buildings or additi<jORln1~Sii~~~1~i~dG9[~PJ:;.x"Qf
altered existing buildings, submit this completed and signed form to: " ,~v 1,1 Lh..'17tLUt'a1!JEN j
· 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 wit~ inf~~ti~~ y~~~;jr.
Transaction 10 Number /" ;(:;/~e- ~ ~
Site Number ~
Site location (number & street) 'P t;?~ , .--.L
~Cjly 0 Village 0 County of 6;27~~? -e
2. PURPOSE OF THIS STATEMENT: (Check Box A, By C, or D to ind..i.cate purpose and complete any other. /
applicable boxes and infonnation. Attach additional pages if ~ry;J, / d. h
Check those which apply: 0 Building Object 10 # _,~.{lVAC Object ID # OSfl. '269' ~
o Lighting Object 10 # . ~ )/6 c::::> joJ"/7 ...
o Partial Completion
Description of Portion Completed
~ Statement of Substantial Compliance
To the best of my knowledge, belief, and based on onsite observation, construction of the following building anelor
HVAC items applicable to this project have been completed in substantial compliance with the approved plans and
specifications.
o BUILDING/LIGHTING ITEMS
1. Structural 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 forward flow on back flow devices) by appropriately registered
professionals
3. Shaft and stairway enclosure
4. Exits including exit and directional lights ~
5. Fire-resistive construction, enclosure of hazards, fire walls, labeled doors, class of HVAC ITEMS
construction, fire stopped penetrations
6. Sanitation system (toilets, sinks, drinking faCilities) 1. HVAC system including final test
7. Barrier-free including Comm 18 elevators and lifts 2. All conditions of HVAC plan approval and
8. Energy envelope requirements applicable variances
9. All conditions of building plan approval and applicable variances
10. Exterior lighting & control requirements
11. Interior lighting & control requirements
12. All conditions of lighting plan approval
and applicable variances
The foJlowingltems are not in compliance and must be addressed:
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 c:bove to indicate project status as of this date.)
D) 0 Pr~ectAbandoned
3. SUPERVISING PROFESSIONAL SIG~~ ~ ~;) /:d
o Building ~HVAC 0 Lighting_ < ...? ~#/ Date .
~ Name (please print or type)
Pho~ number ~ ,- ~~ Customer ID # ~rCJt?.9 Signature ~
( ;?tJ'b/ 7(f. ~