HomeMy WebLinkAbout2005-Compliance Statements
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Buildings, HVAC Compliance Statement SBO-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 form 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, 10541N Ranch Road, Hayward, WI 54843
Personal infonnation 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 ID Number 937355
Site Number 667578
Site location (number & street) 486 WYLDEWOOD 6 UNIT #12
o City 0 Village 0 Town Of OSHKOSH County of WINNEBAGO
2. PURPOSE OF THIS STATEMENT: (Check Box A, B, C, or 0 to indicate purpose and complete any other
applicable boxes and information. Attach additional pages if necessary).
Check those which apply: 0 Building Object 10# 928336 0 HVAC Object 10# _
o lighting Object 10#
o Partial Completion
Description of Portion Completed
A} 0 Statement of Substantial Compliance
To the best of my knowledge, belief, and based on 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,
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 construetion, fire stopped penetrations
6. Sanitation system (toilets, sinks, drinking facilities)
7. Barrier-free including Comm 18 elevators Bnd lifts
8. Energy envelope reqUirements
9. All conditions of building plan approval and applicable variances
The following 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
o 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 F
o Building 0 HVAC 0 Lighting \ 10/14/2005
Phone #
920-497-5007
Customer 10#
SBD-9720 (R.OJ/2003)
, ~~ form ~ requ~ Lobe .U~~~n~s~~:;,'P~~~~~~':~~AC dnignor or ~'-'I e:~~
, ~es;~~r} ocservlng c;onstJ\letion ,Of prO!ec:s W!tl'lln buildlnS$ with ~I are2S ~O.OOO cubl~ fee~ or greater and b1esenerS'''f!'E /
{Comm SO.10/Comm G1.50). i=sllure lCl ~ubmitthis form may result In penalties as spec:med In Comm 50.26/Comm 61 .23 '
anC/or local ordinances.
Generallnstrudicns: Prior to the initial occupancy of new bt.lildings or additions and the final occupancy of
altored existing byildings. submit this completed and signed form to:
. The municipal building inspection office 2nd
. Safety and Buildings. 10541 N Ranch Road Hayward. Wi. 54843
Person21lnfarm:3tJon you provlce m:ly be used tor SQCOndary PUrpol~' [Privacy L.aw. I. 15.04 ('1){m)].. .
1, PROJECT INFORMATION: Please fill in the following with information from your pl~n a~pT'ovallel:t5:r.
Transaction 10 Number t17 L (J 4 '3 .
Site Number I.. ~ 7-.tS 1 ~
Site loCJtion (numbe~ & street) tJ'I / d rc: WdA ~ J/,I ~;:- - O,AI! iJ4h:J /4, .; LJ,.,. 2.4z:. ,[./
cYCity 0 Village 0 Town of ~ 5 h ~ s J., County of 4/. .., AI e 6~ "
2. PURPOSE OF THIS STATEMENT: (CMel<. Box. A. 8. C. or 0 to incic:.E.,a ~ur;jos.. :;1':<: C;:l:7:;lete ...~y othe~
e~~lIc;.able boxes 2nd ioform~tion. At'"~ch .<:ditlol'lal p;;ges it nece!:sary.)
Check thOS~ w~ich cpply: Cl Suilcin~ O~jec\ 10 # c: t-:VAC C:>je::t 10 ~ gA ~ 9 ).~
W Lit;htin!:; Objec~ 10 ~ c:p. rtJ 1'Q) if r~
.- ?~~;a: Cc~~:e~~"n
Dese:"'I'tIOn cr :=-ort.lon C<:m~l.tl:~
A) ~ $fatement of Subs':antial Compliance
T:) tM ::les: of my l<:'low1e-:se. ~e:ie~. Cll'l~ ~ase~ ;)1"\ cr.s:te ::lCS!;!!V..ticn. :::r:s::l.:::::cr; c~ :~e ~ciiC''',ir.S ;~Ii<:im; .n~:c.. r.!..V~,:
. ittms ao~lita~lc to ~is ~rOlfil'=: r:ave ~ee~ c::)m;::i~~= itl !l~~S':Cl;;'::aL c::>m;:ii.r:ca wit~ :r:! ~:::::~Cv,!::: :>io:'lS a~,=
s~e::::ficatio~s .
- BUIL.OINGILlGHl'lNG 1~~S
, S~c::"":~1 ,..,.,t.~ 1r.~l.I':::r:i !I;~~i.\i:-..,! _:':~ e~!!~':.::;n ::~ .Iti ;;':';;\Ci~'W ~::-;";:;:"'.'~~
t:-.;:se.e::. ;:'~::as:. ;-;-.v~t :\J11C::"'.!;. @~:.)
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2. ~::-e ;:::"e~:=ic." $vS~G~: (!=:-;I~J(~@~!. ;S~Cl:"':T"..s. 1~;III.C1 ~ete'::::!":a, -=.Si~E::,
iI'\S:.;:llcC. ~l'(: ~.s~.:: (in~~o:".;;: :c::-,.gre ~c... ct". :;,JO: ~:;.. :...i:ul =~
.=:fco~a:a~y re:i~t!~!:C .:rc~e~~c:r..m:;
3. SPur.~ =nc G1irwa.. ene:c~:.:re
.!.. ~1II ir.c!uC:ing exit ..n~ di",::C:'l~ :;g~u
I: Prl:l.~~s:iv. c:::"tl-:Ndon. .~c:C:I~rQ c~ h.~:,,;:s, ~ae w:iI~:S. l;i:;e.~~ ':::-5. ::;:as.
01 c;;~'::-~c:"'..cP'l. fire s:o~;::.!: oe!'Ill:'-';'OOf:5
_. S;>~~ticn $ys~::'\ (toile:.. Sltllr.S. c~.j(:..", r:;~iilllP!o)
7. c~~,,"irel: :!:d~d!:'l' Ccr::l':'l Hl e~t\o/&:crs Cl".:: lii"~
e. E:1e~y l!nvcl~e reGui~rr."'1:S
S. All Q;r.;::t~O~$ c;;f ~ji~il1" ;llan &;:):::rovalar.c: 1I.;:~1i~'l! var!ance3
~~. ..;,: -:;:"::::~:.:="':s ~7 .:;.-.:;:-:; ::s~ ~:::":''-'.
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= 11'v'.c.C 1,;;,)'IIlt
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t:. ~.n ~::-:.c:~:c:":e .:~ !I"'.'"i;":' :::if. !::~"c; ;'i"".:::
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T"n~ following itRms are not in compliance and mu:':~ l:le address~~: D. 0"':" .$'~7. 6-/..,Jc ,,.,k;
~~~.
B) 0 Statement of Noncompliance
Ol.:e tc the following listed viola:lOriS. this ~roje<:: is riot re:ol:y for ee::::"::J.!'Cf:
C) . 0 Sl.lpervising PrClfessicnal Withdrawn From Projef;c (USi A or C a:;O\le to ir.c;ieii,a ~:j;,;: s:..~us as of ...'":is ,..=~.)
D) u Project Abandoned
3. Su?'ERVlSING PROFESSIONAL SlG
::J E!\liic5ing ~VAC 0 U!j;htins; ~ <. we./L
Name (olea" CI . c: ~.)
C~stomer 10 ~ "'8~ 1'1(
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j:lp,one j,.;mber 9;)..t;- 745' .:
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