HomeMy WebLinkAbout2007-Certificate of Occupancy
CITY HALL
Inspection Services Div
215 Church Avenue
PO Box 1130
~ ~~:;:~r,6
OfHKOfH
ON THE WATER
City of Oshkosh
Approved: 10/31/2007
Issued: 11/02/2007
Wyldewood Village Apartments LLC
2990 Universal St Suite A
Oshkosh WI 54904
CERTIFICATE OF OCCUPANCY
An Occupancy Permit is hereby issued for the new 16-unit apartment building located at
140 Wyldewood Dr, Oshkosh WI as described in Building Permit Number #121198.
This building is to be used only as a multi-family residence and is located in the R-3
Multiple Dwelling District.
LIMITATIONS:
Maximum number of persons and/or living units: Sixteen living units
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 areavailable upon request inroom 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~r~~
Building Systems Inspector
cc: Midwest General Contractors Inc
.~
Building Permit Work Card
Job Address 140 WYLDEWOOD DR Permit Number 0121198 Create Date 8/22/2006
Owner MIDWEST GENERAL CONTRACTORS Contractor MIDWEST GENERAL CONTRACTORS INC
Category 130 - New Multi-Family Plan U8-84-0806
Occupany Permit Required Flood Plain No Height Permit Not Required Class of Const:
Use/Nature COMM/16 unit multifamily, non-sprinklered. 8 units on the 1st floor and 8 on the 2nd floor.
of Work
HVAC Contr BREWER HEATING Plumbing Contr WATTERS PLUMBING
Electric Contr CUMINGS ELECTRIC INC
Inspections:
Date 11/3/2006
[Fa' ,"",est
Date/Time requested: 11/2/2006 02:48 PM
Access: I
Requested By: JOHN ~KOTZKE CONCRETE CONST
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Type Footings
Inspector Nicole Krahn
approved
Notice Type:
Ready Date/Time:
11/3/2006 01 :30 PM
Phone Number~ 231-1667
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Date 11/9/2006 Type Foundation Backfill
Request Line / Ready for a backfill inspection
Inspector Nicole Krahn
approved
Date/Time requested: 11/8/2006 12:34 PM Notice Type:
Access: !Please notify Andrew Lang of the inspection
Requested By: MIDWEST GENERAL CONTRACTORS INC-Andy
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Ready Date/Time: 11/8/2006 12:34 PM
Phone Number: (920) 410-0864
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Date 7/20/2007 Type Rough In Inspector Nicole Krahn
1) Properly firestop flexible water lines (remove the insulation or provide UL listing allowing the insulation)
2) Remove all mold on the drywall seperation between units
not approved
Date/Timerequested: 7/17/2007 11:43AM Notice Type: FC
Access: I
Requested By: MIDWEST GENERAL CONTRACTORS INC
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Ready Date/Time: 7/20/2007
Phone Number: Jay - 420-5878
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Date 7/25/2007 Type Re Rough In Inspector Nicole Krahn
roo,est ""
Date/Time requested: 7/20/2007 10:05 AM Notice Type: Ready Date/Time: 7/25/2007
Access: ICall Jay for key - 420-5878
Requested By: MIDWEST GENERAL CONTRACTORS INC Phone Number: Jay - 420-5878
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
approved
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Page 1 of 2
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Building Permit Work Card
Job Address 140 WYLDEWOOD DR Permit Number 0121198
Create Date 8/22/2006
Owner MIDWEST GENERAL CONTRACTORS
Contractor MIDWEST GENERAL CONTRACTORS INC
Plan U8-84-0806
Category 130 - New Multi-Family
Occupany Permit Required Flood Plain No Height Permit Not Required Class of Const:
Use/Nature COMM/16 unit multifamily, non-sprinklered. 8 units on the 1st floor and 8 on the 2nd floor.
of Work
Plumbing Contr WATTERS PLUMBING
HVAC Contr BREWER HEATING
Electric Contr CUMINGS ELECTRIC INC
Inspections:
Date 7/25/2007 Type Insulation Inspector Nicole Krahn approved w/cond.
NOTE: Sound insulation was not installed between the units at the stairwell walls. The north east unit on the 2nd floor was not finished.
Date/Time requested: 7/25/2007 12:53 PM
Access: I
Requested By:
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
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Date 10/22/2007 Typ~"Finai""~";~ Inspector Nicole Krahn
.""
REQUEST LINE / READY FOR A FINAL INSPECTION
Notice Type:
Ready Date/Time:
7/25/2007 12:53 PM
Phone Number:
Date/Time requested: 10/17/2007 09:34 AM Notice Type: Ready Date/Time: 10/19/200700:00
Access: !CALL JAY WITH MIDWEST, HE WILL GET YOU IN AND WOULD ALSO LIKE TO BE PRESENT FOR THE INSPECTION
Requested By: MIDWEST GENERAL CONTRACTORS INC - Jay Phone Number: (920) 420-5878
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
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Page 2 of 2
Electric Permit Work Card
Job Address 140 WYLDEWOOD DR Permit Number 124736
Owner MIDWEST GENERAL CONTRACTORS
Service . New 0 ChangeO Temp 0 N/A
Volts 120/240 Circuits
Amps 800 Switches 160
Create Date 8/22/2006
Contractor CUMINGS ELECTRIC INC
I Type 0 Overhead . Underground 0 N/A
Luminaires 240
Receptacles 320
$35,000.00
Value
Use/Nature 631 - Residential-New Multi-Family Wiring COMM/16 unit multifamily, non-sprinklered. 8 units on the 1st floor and 8 on
of Work he 2nd floor. Permit to include temporary service.
Inspections:
Date 05/10/2007 Type Temporary
Faxed approval to WPS 5-15-07 7:30 AM
Re-faxed approval to WPS 5-22-07 8:00 AM
Inspector Adam Krause
approved
Date/Time requested: 05/10/2007 01:10 PM
Access:
Requested by: CUMINGS ELECTRIC INC - Jan
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Date 07/19/2007
Type Rough In
Request line
K.O. closure missing in 204 electrical panel
Reviewed with electricians on site
Notice Type:
Ready Date/Time: 05/10/2007 01: 1 0 PM
Phone Number:
. Inspector Kevin Benner
approved w/cond.
Date/Time requested: 07/19/2007 07:19 AM
Access:
Requested by: CUMINGS ELECTRIC INC - Jan
Notice Type:
Ready Date/Time: 07/19/200707:19 AM
Phone Number:
Date 07/20/2007
r"'os! 110'
Faxed to WPS 7/20/7
Type Service
o Reinspect Fee Paid
approved
o Reinspect Fee 0 Fee Wavied
Date/Time requested: 07/19/2007 12:48 PM
Access:
Requested by: CUMINGS ELECTRIC INC - Jan
Inspector Kevin Benner
Notice Type:
Ready Date/Time: 07/19/200712:48 PM
Phone Number:
o Reinspect Fee 0 Fee Wavied
o Reinspect Fee Paid
Date 09/05/2007 Type Underground Inspector Kevin Benner approved
Perimeter Lighting Only! One side was done and backfiled when the inspection was conducted. Steve C. the electrician on site suggested
hat I return later to inspect the remainder.
Date/Time requested: 09/05/2007 08:41 AM
Access:
Notice Type:
Ready Date/Time: 09/05/200710:00 AM
Phone Number: 231-5946
Requested by: CUMINGS ELECTRIC INC Richard
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Electric Permit Work Card
Job Address 140 WYLDEWOOD DR Permit Number 124736
Owner MIDWEST GENERAL CONTRACTORS
Service :. New 0 ChangeO Temp 0 N/A
Volts 120/240 Circuits
Amps 800 Switches 160
Create Date 8/22/2006
Use/Nature ~31 - Residential-New Multi-Family Wiring COMM/ 16 unit multifamily, non-sprinklered. 8 units on the 1st floor and 8 on
of Work he 2nd floor. Permit to include temporary service.
Contractor CUMINGS ELECTRIC INC
I Type 0 Overhead . Underground
Luminaires 240
Receptacles 320
o N/A
Value
$35,000.00
Inspections:
Date 09/05/2007
Type Underground
Inspector Kevin Benner
approved w/cond.
Perimeter Lighting Only! Field Request
DatelTime requested: 09/05/2007 10:00 AM
Access:
Requested by:
o Reinspect Fee 0 Fee Wavied
Notice Type:
Ready Date/Time: 09/05/2007 00:00 AM
Phone Number:
o Reinspect Fee Paid
-- - - - - ---- - - - - - ---- - - ---- --- - - --- - - ---- -_.---- - ----- -- - - - .--- - - -_.- - - - ---- - - - ----_.--- - - --- - - - ----. - --- -- - - - -- - - - - ----- - - -- - - - ---- - - - - --- - ---- - ---- - - - -- ----
Date 10/29/2007 Type Final Inspector Kevin Benner not approved
Request line \ The FCN states that the I faxed this to the E.C., this is incorrect I reviewed the FCN with Wes on the phone.
DatelTime requested: 10/26/2007 06:59 AM
Access:
Notice Type: FC Ready Date/Time: 10/26/2007 06:59 AM
Requested by: CUMINGS ELECTRIC INC - Jan
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Phone Number:
------------------------------------------------------------------------------------------------------------------------------------------------------------
Date 10/30/2007
Type Re Final
Inspector Kevin Benner
not approved
REQUEST LINE / READY FOR A FINAL REINSPECTION
NO ACCESS / Faxed to E.C. 10/30/7
DatelTime requested: 10/30/2007 07:14 AM
Access:
Requested by: CUMINGS ELECTRIC INC - Jan
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Notice Type:
Ready Date/Time: 10/30/200707:14 AM
Phone Number: (920) 231-5946
------------------------------------------------------------------------------------------------------------------------------------------------------------
Date 10/31/2007 Type Re Final Inspector Kevin Benner approved w/cond.
Inspection for the garage reveiwed that an UG & R/I inspection was never requested or conducted. I cannot verify the wiring above the
drywall ceiling in the garage or the UG wiring to feed the garage.
Date/Time requested: 10/31/2007 06:55 AM Notice Type:
Access: Call Wes to meet on site to gain access
Requested by: CUMINGS ELECTRIC INC
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Ready Date/Time: 10/31/200700:00 AM
Phone Number: 858-9828 Wes
------------------------------------------------------------------------------------------------------------------------------------------------------------
~
CORRECTION NOTICE / FIELD INSPECTION REPORT
JOB LOCATION: \ 4,c;:, ~/l~~~
I
CONTRACTOR: C u.f"r\,~~ ~\.et' J- r. ~
PROJECT TO BE INSPECTED: N ^^F"O t b L\.f"\~..\::.
~ --
TYPE OF INSPECTION: ~ \. c..\'~\L.
~
City of Oshkosh
/'....-.'"spection Services Division
I ;15 Church Avenue, PO Box 1130
Oshkosh, WI 54903-1130
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 ofthis notice
and return it to the Inspection Services Division by the Compliance Date of
INSPECTION Rjj:SULTS
~
,
Print Name
Company
Signature:
Date
Job Address 140 WYLDEWOOD DR
HVAC Permit Work Card
Permit Number
123186
Create Date 08/22/2006
Owner MIDWEST GENERAL CONTRACTORS Contractor BREWER HEATING
Fuel ~ Gas I I I Oil I I I Electric I I I Solar U Solid I Value
System 0 New I 0 Replace I D Other
U Forced Air U Radiant I U Steam I U AlC I U Vent
U Electric I ~ Hot Water I U Suppl. I U Con. Burner I
Chimney Type 0 Chimney A 0 Chimney B . Direct Vent 0 Not Applicable
Use/Nature COMM/16 unit multifamily, non-sprinklered. 8 units on the 1st floor and 8 on the 2nd floor.
of Work
$48,600.00
I
I
Inspections:
Date 10/22/2007 Typ~~lill't<
~Vt;;'<::;-<'~;",'I:-.."J":."'''''>'''''' _\;'.'.~c,
Inspector Nicole Krahn
DatelTime requested: 10/22/2007 01 :43 PM
Access: I
Requested By:
o Reinspect Fee 0 Fee Waived
Notice Type:
Ready DatelTime: 10/22/2007 01:43 PM
Phone Number:
D Reinspect Fee Paid
Plumbing Permit Work Card
Permit Number 122341
Contractor WATTERS PLUMBING
Plan V1-217-0906-PD
Create Date 08/22/2006
Job Address 140 WYLDEWOOD DR
Owner MIDWEST GENERAL CONTRACTORS
Category
Bathtub
Whirlpool
Lavatory
Toilet
Res. Sink
Bar Sink
Site Drain
Roof Drain
Misc.
Fixtures
Use/Nature jCOMM/ 16 unit m u ItifamTiy,-non-spnnklerecCSunTis..on-t11e1sHiooranCi8-on.ihe2ndflo()r~.(Installing 17eTectric:.wafer-heatersP'*c:heck-1
of Work (#63831 i
I
i
L
440 - Industrial-Interior
16 Shower
Floor Drain
17 Lndry Tray
17 Disposal
Dishwasher
Sump Pump
17 Classrm Sink
Breakrm Sink
Ejector/Grind
4 hose bibs
Value
$51,116:g0
Water Softner Wait. St. Shamp Sink Coffee Maker
18 Local Waste Ice Chest FlrlWst Sink Int Grease Trap
1 Clothes Wshr 16 Exam Sink Catch Basin Ext Grease Trap
-
16 Bidet Sculry Sink Wash Ftn RPZ Valve
16 Beer Tap Hand Sink Urinal Eye Wash Statn
Lab Sink Plaster Sink Standp Rec 16 Wtr Sewer Mtrs
Sterilizer Surgeons Sink Ice Maker Deduct Meters
Dip Well F Prep Sink Gar Drain Wtr Usage Mtrs
Drink Ftn Serv Sink Soda Disp
-
.
~~.__.-
----. --
Water Heater
-
Size
Material
Type
#
Conn.Type
Sanitary Sewer
Storm Sewer
Water Service
Inspections for Work Card 88138
Date ~~!.2~ Type ~r1.dergro~.':!d____ Inspector r:a~1 W~__________.__ approved
1---------------- ____._.______-'---'-____.'__._..._,__.,--,
fax request
!
I
I
,
I
I
i__ ------------------------------------------_____________________________________~__~____________________,___________ ________J
Date/Time requested: 11/13/200(11 :20 M
Access: [~-- _____ _
Ready Date/Time: 11/13/2.QQ! 93:00 PM __ Requested By: WA lJ:ERS PLUMBING - Jamie
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Notice Type:
Telephone Number:
920-733-8125
--l
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-.. - - - - ~ ~ ~ - - - ~ -- - - -- - - - - - - - - -- - - ~ ----- - ------ - ----- ~ ------ - ----- - - -.. --- ----- - -- - - - ------ ----- - - - - - - ----------- - ---- - ---- - -----. - ----- ------ ----- - ----- - - - --- - -- - - - --- - ~ - -- -. -- - --- - ---- - - --- - ---- - ---
Date 7/16/2007
Type Rough In
Inspector Paul Wolf
approved
!FAXES REQUEST / READY FOR A ROUGH INSPECTION
---1
I
i
I
I
----______________________ _.1
Date/Time requested: 7/10/200709:30 AM
Access: 1--- ---
Ready Date/Time: 7/10/2007 09:30 AI\JL.. Requested By: WATTERS PLUMBING -- Jamie
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
- - - ~ - - - - - - - - - - - - - - - - - - - - - . - - - - - - - - - - - - - '. - - - - - - - - - - - -. - - - - - - - - _. - .'M _ _ _ _ _ _ _ _ _ _ _ _ _ M'. _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __0 _ _ _ _ _ .__ _ _ _ _. _ _ _ _ _ _ _ _ _ _ . _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.
Date 9/28/2007 Typt'rrnaf-~ _ Inspector Paul Wolf ~approved-"
...______ 'ii;~~_==~_=:_..__=______.___=:======._:.=_=__==========:==-- '""'_____=--=~][~________.___._______________.~____________..
IFax--requesC-
i
Notice Type:
Telephone Number:
@20) 71~.::~_~~?__________
I
c_..__~__~__.__~___~_________.
___________________.J
Date/Time requested: ~{~~~~5~~ Notice Type: Telephone Number:
Access: [C~-'CI?y~2_0-58~_____~~~_
.. Ready Date/Time: 9/28/2007 07:59 AM Requested By: WA TTE.RS i'.,=--U_IVIBIN~__
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
920-733-8125
----~----I
___________~__J
OCT-17-2007 06:47 DESIGN AIR
Buildings, HV AC, Lighting Compliance Statement
This form is required to be submitted by the supervisIng professional (architect, engineer, HVAC designer or electrical
designer) observing construction of projects within building.s with total areas exceeding 50,000 cubic feet and constr~ction
f antennas, towers, and bleachers (lLHR 50_1 O). Failure to submit this form may result in penalties as specified in" -
...HR 50.26 and/or local ordinances.
General Instructions: Prior to 'the initial occupancy of new buildings or additions arid the final occupancy of
altered existing buildings, submit this completed and signed form to:
. The municipal building inspection office and
. Safety and Buildings, P.O. Box 7162, Madison, WI 53707-7162
Personal information you provide may be used for secondary purposes [Privacy Law, s. , 5.04 '(1)(m)].
1. PROJECT INfORMATION: Please fill in the following with information from your plan approval letter.
Transaction 10 Number . /34 e1 } <7
III ~I 3
Site location (number & street) / # t,fI,,~ Vh {;J , / /
. ~ity 0 Village 0 Town oJ t;1fft-4.si-l County of _ tt.AP~
2. PURPOSE OF THIS STATEMENT: (Check Box A. S, C, or 0 to indicate purpOSE~ and complete any other
.applicable boxes and information. Attach additional pages if necessary.) .
Check those which apply: 0 8uilding Object ID # [J11'VAC ObjE~ct ID # j I~ '(d 7
o Lighting Object 10 #
10/18/2007 THU 14:57
FAX 920 748 6520 Brewer Heating ~~~ MIDWEST
Site Number
o . Partial completion
~003/003
P.03/03
Description of Portion Completed
A) o Statement of Substantial C<<;lmpliance
To the best of my knowledge, belief, and based on onsite observation. constrvctiOl'1 of the following building and/or HV AC
iterrfs applicable to this project have been completed in substantial compliance With the approved plans and
specificationl;>.
C1 BUILDING ITEMS
1, Structural system including subminal and erection of all building
components (trusses. precast, metal building, elc.)
2_ Fire protection systems (sprinklers. alarms, smoke detectors) designed,
. installed. and tested (including forward flow on back fiow devices) by
appropriately registered professionals
3. Shaft and stailWay enclosure
4. Exits including exit and directional lights
5. Fire~resistive construction, enclosure of hazards. fire walls, labeled
doors, class of construction
6. Sanitation system (toilets, sinks, drinking faclHties)
7. Barrier-free including Comm , 8 elevators and lifts
8. lLHR 63 energy envelope
9. All conditions of building plan approval and applicable variances
The following items are not in compliance and must be addressed:
o HV ~.C ITEMS
1_ HVAC system inch.lding final test
(ILHR 64.53)
2. All conditions of HVAC plan approval and
applicable variances
o LIGHTING ITEMS
1. Exte:rior lighting & control requirements
2. Intelior lighting & control requirements
3. All conditions of lighting plan approval and
applicable variances .
B} Cl 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 8 above to indicate project status as of this date.)
0) O. Project Abandoned
~~ SUPERV1S.ING PRQFESSIONAL. SIGN~E FOR: /'
/ CJ 8!Jilding tYHVAC I:l lighting ~Uu' ~ 6~ -e,/?:.- joate I till (.. (41
Name (please print or type) / / ). f1
Phone number f~--l41 Customer ID # ~ l' S;2 f I { S,ignature ~ ~~ ~.
Jr!'1
SBD-9720 (R,OS/98)
TnTA! P_Vl<:
Buildings, HV AC 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 greati'"r~lJd
bleachers (Comm 50.10/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.
Gener,aJ 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 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 ID Number f259405
Site Number 711513
Site location (number & street) 1411 WILDEWOOD 16 UNIT BLDG. 0
o 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# 1041328 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. Sh;:lft and stairway 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 and lifts
8. Energy enyelope 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. S'lPERVISING PROFESSIONAL SIGNATURE FOR:
o Building 0 HVAC 0 lighting DONALD HAANEN 10/8/2007
Name (please print or type)
Phone # (920) 497-5007 Customer 10# 649536 Signature
8BD-9720 (ROI/2003)