HomeMy WebLinkAboutCertificate of Occupancy
CITY HALL
Inspection Services Div
215 Church Avenue
PO Box 1130
Oshkosh WI
54903-1130
City of Oshkosh
OfHKOfH
ON THE WATER
Approved:
Issued:
10/10/2007
10/11/2007
River Valley One LLC
222 Ohio St
Oshkosh WI 54902
CERTIFICATE OF OCCUPANCY
An Occupancy Permit is hereby issued for Fed Ex Kinkos located at 530 S
Koeller St as described in Building Permit #126430.
This space shall be used for retail/sales and is located in the C-2 General
Commercial District Planned Development.
LIMITATIONS:
Maximum number of persons: 19 occupants
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 orderfor this certificate to be ~9)id.
/;
cc: Division 21 Inc
Building Permit Work Card
Job Address 500-550 S KOELLER ST Permit Number 0126430 Create Date 8/22/2007
Owner RIVER VALLEY ONE LLC Contractor DIVISION 21 INC
Category 230 - New Stores & Customer Service Plan X8-1946-0407
Occupany Permit Required Flood Plain Height Permit Class of Const:
Use/Nature 530 S Koeller /Interior build out of tenant space for Fed Ex Kinkos.
of Work
.
HV AC Contr Plumbing Contr OGDEN PLUMBING
Electric Contr SUBURBAN ELECTRICAL ENGINEERINI
Inspections:
Date 8/27/2007 Type Rough In Inspector Allyn Dannhoff
r,q".., ""'
Date/Time requested: 8/24/2007 09:22 AM Notice Type: Ready Date/Time: 8/27/2007 AM
Access: I
Requested By: Todd Phone Number: 761-291-5364
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
no time
Date 10/1/2007 Type Final Inspector Nicole Krahn
Request line / Please call Todd to confirm inspection time. (Todd would also like to be present for the inspection)
not approved
Date/Time requested: 10/2/2007 10:02 AM Notice Type: FC
Access: I
Requested By: DIVISION 21 INC - Todd Johnson
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
Ready Date/Time: 10/1/2007 00:00 AM
~
Phone Number: (763) 291-5364
Date 10/4/2007 Type Re Final
jWaiting for building and hvac compliance statements.
Inspector Nicole Krahn
not approved
Date/Time requested: 10/4/2007 12:34 PM Notice Type: FC Ready Date/Time: 10/4/2007 12:34 PM
Access: I
Requested By: Phone Number:
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - -- - - - - - - - - - - - - - -'- - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - - -- - - - - - - - - -- - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
Date 10/1 0/2007 T~Fina.r .!'~ Inspector Nicole Krahn ~~~I>rl),,~~ II
Compliance statement was received. Fire Department approval was granted. .~..--.....
Date/Time requested: 10/10/2007 07:11 AM Notice Type:
Access: I
Requested By:
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
Ready Date/Time: 10/10/200707:11 AM
Phone Number:
Page 1 of 1
Electric Permit Work Card
Job Address 500-550 S KOELLER ST Permit Number 125349 Create Date 6/14/2007
-,--_._._-~--~ --,-- ---~---
Owner '31'{ER -,,!~~~EY ONE LLg_______________ Contractor ~l!.~_~'3E3~!!~~~~~!3ICAl:_~t::J9INE!=RIf\J(
Service 0 N~~___-OCh~-n-g;-O-Te~: -.~~~~=_] Type O_Ov_~r~~~~____O_tJr1~~I]!Ou~(j__._N/A i
Volts Circuits 40 Luminaires 31
Amps_ ______ Switches _____~ Receptacles ______~g
Use/Nature 1643 - Comm-erclal-Addition/RemodelSCOMM-(#530Fed)<:7K1nkos)TfenanfT:ii.lrrcrour--
of Work
Value
..._____~J4,000.:QQ
Inspections:
Date 08/27/2007
Type Rough I~_____ Inspector Kevin Benner
____ approved
~---_._---- -
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Date/Time requested: 98/27/2007 08:33 A~ Notice Type:
Access:
Ready Date/Time: 08/27/200708:33 AM
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid
Phone Number: Peter 841-7095 or 739-5156
~_ ~_ ~ _ _ _ __ _ _ _ _ ___. _ ~ _ _ __ _ __ _. _____ ~ ______ _ ______. __~ _ __ _ __ ______._ _ _ ___ __ _ _ ___. _____ _ .____ _ __ _ _. ____. _ _____ _ _ ___ _ ____. _. ___ _ _ ____ __ _ _ ___ w ____ _ _ ____ _ _ _ _ _ _ _ __
Date 09/11/2007 Type Abv Ceiling Inspector Kevin Benner _______________ approved w/cond.
~~~eo~hs~;ee s~:~~~~~a(~~a~id not want the inspection until the PM.At the time-~ inspe~on~~~re were so~e :~:_::::~-::s~~~- a-n-~~~--l
Iluminaires were not properly secured to the grid. I also inspected the emergency illumination which did not function and the rear was not ;
!planned for. The roof top inspection was also inspected and approved at this time. i
L_________.______.___________.___~____...._._______..___.____._______. ._____.____________._.________._____________._.__.. __.......__._1
Date/Time requested: ~!!J~007__ 0~:4_4 A~_ Notice Type: Ready Date/Time: 09/1~QQI9_~:~4~lIi1___
Access: Technician on site now
Requested by: ~_~~RBAN E!:EC-r:'3IC~_EN~f\J.~~_'3'_NG
o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid
Phone Number: 920-739-5156
w____._._____...______________________________________----------------------------------------------------------------------_._--------.---------------.----
Date Q.~~ Type ~~__ Inspector ~\I~~~_____ approved wieand.
~bove ceil i ng-. Rob called and stated the violations were correded. Installing ceiling tile this AM. \ Most of the ceiling tiles were installecj-afl
C of ,",,'01100, wh,1 w"' ",lbl, 'PI,.,,,d 10 too ok". I did "0110,1 th, ,m",,",,, ""m'''''o",____. ... _~_ ,,___ . .._j
DatelTime requested: 09/11/2007 02:,37 PM
Access:
Notice Type:
Ready Date/Time: 09/11/2007 02:37 PM
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid
Phone Number: 841-7070 Rob
-- - ~~~~ - 09/2-6i2-~(;7 - __w T~~~:- F~~.~r-~,------- - -i~~-~~~~~;-- K~~i~- B~-~~-~~ - ------ ----- - --- - - ------ - --- - ----'o~~a- -- --~~~-
?1T>1~1,~'1;!.\J,-:"&...i:l'.."'~'\':_..~:>:,,."'~~ _ "'~M~~~
IREQUE-STLlNE / READY FOR A FINAL INSPECTION
-*WOULD LIKE INSPECTION 9/26/07 AT 1PM**
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Date/Time requested: 09/26/~07 _ 07:~_~~_~_ Notice Type:
Access:
Ready Date/Time: 09/26/2007 01 :00 PM
Requested by: SU~~RB~~~~C.IBI_~_L EN~!'l!_~I3~~
o Reinspect Fee 0 Fee Wavied D Reinspect Fee Paid
Phone Number: @20)~41-?gX.o__I3<:>!=>__.
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ w _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~ _ _ - - _ _ - - - - . - --
HVAC Permit Work Card
Job Address 500-550 S KOELLER ST Permit Number
124884
Create Date OS/21/2007
Owner RIVER VALLEY ONE LLC Contractor QUALITY MECHANICAL INC
Fuel ~ Gas I U Oil ~ Electric i U Solar U Solid I Value
System 0 New D Replace I D Other
~ Forced Air U Radiant I U Steam I ~ NC I U Vent
U Electric I U Hot Water I U SuppL I U Con. Burner I
Chimney Type 0 Chimney A 0 Chimney B 0 Direct Vent . Not Applicable
Use/Nature. 530 S Koeller - Fed Ex/Kinkos - Install HVAC system for this tenant space.
of Work
$21,185.00
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Inspections:
Date 10/1/2007 Type Final
Inspector Nicole Krahn
not approved
Date/Time requested: 10/10/2007 07:12 AM
Access: I
Requested By: Phone Number:
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
- - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - -- - --- - - --- - - - - - - - - - - - - - - - - -- - - - - - -- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -- - - - - - - -- - - - - - - - - - - --- - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - - --
Date 10/3/2007 TypTFink...... Inspector Nicole Krahn
'€::B:L~~,~ <~
Notice Type: FC
Ready DatelTime:
10/01/2007 07:12 AM
DatelTime requested: 10/10/2007 07:13 AM
Access: I
Requested By:
o Reinspect Fee 0 Fee Waived
Notice Type:
Ready DatelTime: 10/03/2007 07:13 AM
J
Phone Number:
D Reinspect Fee Paid
Job Address 500-550 S KOELLER ST
Owner RIVER VALLEY ONE LLC
Category 440 - Industrial-Interior
Bathtub
Whirlpool
Lavatory
Toilet
Res. Sink
Bar Sink
Water Heater
Site Drain
Roof Drain
Misc.
Fixtures
Use/Nature !COMM (530 S Koeller St- Fed Ex Kinko's)/Interior plumbing above ground work with electric water heater. Underground roughed by
of Work lathers under permit #124699.
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Plumbing Permit Work Card
Permit Number 126384
Contractor OGDEN PLUMBING
--
Pian Y1-244-0407-P
Create Date 08/21/2007
Value
$5,920.0Q
Shower Water Softner Wait. St. Shamp Sink Coffee Maker
Floor Drain 3 Local Waste Ice Chest FlrlWst Sink Int Grease Trap
2 Lndry Tray Clothes Wshr Exam Sink Catch Basin Ext Grease Trap
2 Disposal Bidet Sculry Sink Wash Ftn RPZ Valve
Dishwasher Beer Tap Hand Sink Urinal Eye Wash Statn
Sump Pump Lab Sink Plaster Sink Standp Rec Wtr Sewer Mtrs
Classrm Sink Sterilizer Surgeons Sink Ice Maker Deduct Meters
Breakrm Sink Dip Well F Prep Sink Gar Drain Wtr Usage Mtrs
Ejector/Grind Drink Ftn Serv Sink Soda Disp
Sanitary Sewer
Conn.Type
Storm Sewer
Water Service
Size
Material
Type
#
Inspections for Work Card 93738
Date ~2~!2_0.QZ_ Type Roughl~_________ _ Inspector ,=-a_~~"0I~_____ _____ approved w/cond.
~rap-primer-valvesnotinstarreddue to air test. Trap primers co-mPly-v;,TiFl Ass-noTa.------------------------------------------------1
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Date/Time requested: 8/23/200701 :36 PM Notice Type: Telephone Number:
Access: [=~_~=-=------------------------~=_=______
Ready Date/Time: 8/23/2007 01 :36 PM Requested By: OGDE_N PLUMBIN~__________
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
--==~-=--=---=--=~
Date 9/26/2007
Type Final
Inspector Paul Wolf
not approved
rr\loaccess fo trap primer valves and no approved plan onsite.
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_.,_._<___._,____ ___"_m_m'_.._,_._ ___....._.. _..n_____.__.______._ ____ ______-l
Date/Time requested:
Access:
Ready Date/Time: 9/2~?QQL _..:..________ Requested By: ~ivisio_rl~1____ Todd_______________
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
9/25/200709:04 AM
Notice Type:
Fe
Telephone Number: 763-291-5364
Date 9/27/2007
Inspector Pa~1 Wolf _______________ app-rove
fccesscovers Tnsta lIe-a-m restroo~--
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Date/Time requested: ~~_09:17 AM Notice Type: Telephone Number: _____________________
Access: L=-~-- --==-___ ---------------------1
Ready Date/Time: ~/27/2007 09:17 AM Requested By: OGDEN PLUMBIN~______
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
~
CORRECTION NOTICE / FIELD INSPECTION REPORT
JOB LOCATION: S:5:> S ~~<t.JL
CONTRACTOR: b\ \) \'S::J..~ d \:p()~
PROJECT TO BE INSPECTED: ~ L'f-..- ~\ U-D'='2::::>
TYPE OF INSPECTION: r:: ~ I r::- ~~
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City of Oshkosh
Inspection Services Division
215 Church Avenue, PO Box 1130
Oshkosh, VVI54903-1130
Phone: (920) 236-5050
Fax (920) 236-5084
Violations must be corrected and approved within 30 days unless otherwise noted. Call for re-inspections prior to concealment
and/or occupancy. Upon completing the corrections, the owner/contractor/agent must sign and date at the bottom of this notice
and return it to the Inspection Services Division by the Compliance Date of
ttEl\oI# '.CO])E INSPECTION RESULTS . ......./.j; ""
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Phone #
Print Name
Company
Signature:
Date
~
CORRECTION NOTICE / FIELD INSPECTION REPORT
~
City of Oshkosh
Inspection Services Division
215 Church Avenue, PO Box 1130
Oshkosh, VVI54903-1130
Phone: (920) 236-5050
Fax (920) 236-5084
JOB LOCATION: ~ S ~~
CONTRACTOR: b\.JfS.\OtJ 2.\ ~C-
PROJECT TO BE INSPECTED: K.l::> ~ ~\~ ~LbOu-
TYPE OF INSPECTION: ~ ~ J ~rh.t\L
Violations must be corrected and approved within 30 days unless otherwise noted. Call for re-inspections prior to concealment
and/or occupancy. Upon completing the corrections, the owner/contractor/agent must sign and date at the bottom of this notice
and return it to the Inspection Services Division by the Compliance Date of
CODE INSPECTION RESULTS
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Phone #
Print Name
Company
Signature:
Date
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OJHKOfH
City of Oshkosh
Division of Inspection Services
215 Church Avenue
PO Box 1130
Oshkosh WI 54903-1130
www.cLoshkosh.wi.us
"
ON THE WATER
April 12, 2007
Mike Oxley
WD Partners
909 Lake Carolyn Pkwy Ste 600
Irving TX 75039
Fred Jacques
Alliance Developement
601 Oregon St Ste A
Oshkosh, WI 54902
Site: Plan Number: X8-1946-0407
FedEx Kinkos
530 S Koeller St
Oshkosh WI 54902
For:
Description: Tenant space alterations
Object Type: Building and HV AC
Class of Construction: lIB -1992 Sq Ft.; sprinklered
Occupancy: M: Mercantile / Retail
Maximum No of Occupants: 19
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and
Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defmed in Chapter
101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements
Key Item(s) / Conditions:
· IBC 711.3 Any penetrations of fire rated assemblies are required to be protected with a listed firestopping
system that matches the rating of the wall assembly being penetrated. Copies of the firestopping systems
are required to be provided at the time of inspection.
· IFC 901.4 Fire protection systems shall be maintained in accordance with the original installation
standards for that system. Required fire protection systems shall be extended, altered, or augmented as
necessary to maintain and continue protection whenever the building is altered, remodeled or added to.
Alterations to fire protection systems shall be done in accordance with applicable standards.
· IBC 1003.2.11 Means of egress illumination is required to be installed per this section. All paths of egress
through The Retail Display area are required to have adequate emergency lighting to meet the performance
requirements ofIBC 1003.2.11.3. Including the exterior side of doors out of the space. Depending on
configuration of store displays additional emergency illumination may he required to comply with these
requirements.
l:\JnspectiuJ]S\P!an .Rev!ew\Conrrnt:.n:ial Plan Review 2007\X8- (946-0407 530 S Kodkr Sf Bklg & HVAC.doc
Page 1 of3
.E;
. IBC 1209.1 Provide toilet room floors with smooth, hard, nonabsorbent surface extending minimum 6
inches up onto walls. Sheet A-l 0 indicates a 4 inch Base - please change to the required 6 inch
.,""
. NEC 600.3 All electric signs shall be listed and installed in conformance with that listing. The listing label
shall be externally visible after installation.
. NEC 600.6 Each sign shall have a disconnecting means in conformance with NEC600..6.
. IMC 302.1 The building or structure shall not be weakened by the installation of mechanical systems.
Verify that existing structure is capable of supporting the additional weight of the proposed rooftop
equipment. Verify that the existing structure is capable of supporting the weight of the proposed rooftop
equipment.
. IMC 403.3 [Comm 64.0403 (6)] Ventilation rate. Janitor closets. A janitor closet that has only one
service sink may be provided with either natural ventilation via a window or louvered opening with at least
2 square feet (0.2 m2) of area openable directly to the outside or mechanical exhaust ventilation as
specified in Table 64.0403. Plans submittedfor HVAC review do not show the required exhaustfor the
service sink included in building plans. Comm 62.2900 (2) requires a service sink to be located in a
janitors closet, and the IMC requires ventilation of that space. Provide information / details showing
how required ventilation will be provided.
. IMC 606.2.1 Smoke detectors shall be installed in return air systems with a design capacity greater than
2000 cfm.... Verify that duct detectors are installed.
. IMC 606.4.1 The duct smoke detectors shall be connected to a fire alarm system. The actuation of a
smoke detector shall activate a visible and audible supervisory signal at a constantly attended location.
. IFGC 401 /Comm 65.0400 All gas piping and gas piping installations shall comply with NFP A 54,
National Fuel Gas Code.
. IBC l101.2/ANSI All7.1-308.2 & 3 - Mechanical system controls shall be located a maximum of 48"
above the finished floor if the floor space allows a forward approach by a wheel chair or if the clear space
allows a parallel approach.
. Comm 61.30(3) This review does not include lighting. Corom 63.0001 Prior to installation, lighting
plans and calculations shall be prepared in compliance with the code. The plans shall be available upon
request.
. Comm 61.31(4) Revisions to approved plans. All proposed revisions and modifications which involve
rules under this code and which are made to construction documents that have previously been granted
approval by the department or its authorized representative, shall be submitted to the office that granted the
approval. All revisions and modifications to plans shall be approved in writing by the department or its
authorized representative prior to the work involved in the revision or modification being carried out. A
revision or modification to a plan, drawing or specification shall be signed and sealed in accordance with
Corom 61.31(1).
. Comm 61.50 (4) Supervision. Prior to the initial occupancy of an alteration the supervising professional
shall file a compliance statement form SBD-9720 with this office.
hlnspedionsiPbn Review\(\llllmen:iaJ .Hm Revi",,,, 2007\X8-! 946-0.:107 530 $ Kn",.1ler $rBldL! & IIYAC.dol'
Page 2 00
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· Comm 80 This plan review does not include plumbing. Prior to installation of plumbing, plans and
calculations are required to be submitted and approved.
· MUN 30 This review does not include review for signage. Applications for and questions regarding
signage permits should be directed to Todd Muehrer - Associate Planner (920) 236-5057.
· MUN 30-35 (1)(5) All rooftop and ground level mechanical equipment and utilities shall be fully screened
from view of any street or residential zoning district. Contact Todd Muehrer - Associate planner (920)
236-5057 for additional information on screening requirements. All screening shall be properly anchored
in place to resist wind loads. Additionally me 1608.8 Roofprojections - Drift loads due to mechanical
equipment, penthouses, parapets and other projections above the roof shall be determined in accordance
with Section 7.8 of ASCE 7. No HVAC permit will be issued until screening plan has been approved.
A copy of the approved plans, specifications, and this letter shall be on-site during construction. All permits are required to
be obtained prior to commencement of work.
In granting this approval the City of Oshkosh Inspection Services Department reserves the right to require changes or
additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this
review shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the number listed below or the address on this letterhead.
B . oe
Building Systems Consultant
(920) 236-5051 Monday- Friday 7:30 AM. to 8:30 AM and 12:30 AM to 1:30 P.M.
bnoe@ci.oshkosh.wi.us
cc: Property file
Fee Required $
Fee Received $
Balance Due $
450.00
450.00
0.00
l:\insp<x:tiuns'J>lan Revlt:-w\Cllmmerdal P).w Rt'view 2007\X8-) 946-040] 530 S Ko<oller 51 fHdg & IIVAC.dQ,
Page 3 00
ATLANTA
BOSTON
CHICAGO
COLUMBUS
DALLAS
LOS ANGELES
MIAMI
SACRAMENTO
Allpd'M
~~~rtners
WDPARTNERS.COM
7007 DISCOVERY BLVD
DUBLIN OH 43017
614.634.7000 T
614.634.7777 F
iV\.-teCW!-+eJ
RETAIL SOLUTIONS
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OCT 09 2007
DEPARTMENT OF
COMMUNITY DEVELOPfvJENT
INSPEITIOf\l SERVICES DIVISION
T
ITT L
NS
To: Nicole Khan From: Stuart Driscoll
City of Oshkosh Project name: Fed ExlKinko's
Dept. of Inspections 500 S. Koeller St.
215 Church St. WD project #: FXKNSOO83
P.O. Box 1130
Oshkosh, VVI 54903 Date: October 8, 2007
Shipped: Fed Ex
Remarks:
Hello Nicole,
Enclosed is the signed Buildings, HV AC, Compliance Statement.
Regards,
Stuart Driscoll
Name
cc:
BUILDINGS, HV AC, 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 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. This form must be submitted prior to the plan approval expiration date or another submittal may
be required.
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 (refer to the plan approval letter for agency address and
· Safety and Buildings, 10S41N Ranch Road Hayward, Wi. 54843
Note: If the review was done by the municipality, the compliance statement goes only to the municipal building
inspector. A copy is not needed by Safety & Buildings.
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1){m)).
1. PROJECT INFORMA TJON: Please fill in the following with information from your plan approval letter.
Transaction ID Number 1.::2.9 (o(.p \ L Project Name &:>c S. K.b 6~ _ ~ C>5J-\j(CS~ I WI
Site Number I 01..<==\ B I (-pe:p~k::l~~'~)
Site location (number & street) Se>o S. ~OEu....E"R. S~~
~ City 0 Village 0 Town of ~k...Oc;.~ County of W\~toJ.e ~~6
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 # 0 HVAC Object ID #
o Lighting Object ID #
o Partial Completion
Description of Portion Completed
A) ~ 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 0 HVAC ITEMS
of construction, lire stopped penetrations
6. Sanitation system (toilets, sinks, drinking facilities)
7. Barrier-free including Comm 18 elevators and lifts
8. Energy envelope requirements
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
1. HVAC system including final test
2. All conditions of HVAC plan approval and
applicable variances
The following items 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 above to indicate
D) 0 Project Abandoned
3. SUPERVISING PROFESSIONAL SIGNATURE FOR:
II!f" Building iii'" HVAC Ii"'Lighting 5 . $
Name (please print or type)
Phone number 1b14.!b 34-142+ Customer to #
SBD-97:!O (R.04/20051
................. ~. -.... ,..........-..............,