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Compliance Statement
This form is required to be submitted by th. archit<<t. engin.." or HVAC d~9Mf' (supervising ptOf.uional)
observing construction of projects within buildings with total volumes exce.dlng 50.000 cubic f4Mt and construction
of antennas, towers and bleachers (IlHR 50.10). Failure to submit this form may result in penalties as specified in
ILHR 50.26 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 ana signed form to:
TM municipal building inspection office and also to DE
OllHR. Safety and Buildings, P.O. Box 7969. Madison, WI 53r\. eEl \1 ED
1. PROJECT INFORMA nON: (Use the OllHR or municipal project label, or type or print the information.)
Owner Information Project 1m
N~me .. Use
C. ~...J'R-G (-\.
of C~l4lG c.~ LJ
o 8uildin9 and HVAC.
o Pan,a' Completion
Description of poroon Completed
A) .r:::.f. Statement of Substantial Compliance . .
To ttl~ qf my knowledge, belief, and based on on~t~ ot!.SeNanon. construction of the following buildi.n9 ancllot HIIAC itemuppliuble to
"1F:;NGi~:-m w_'_~_-"'__ "'.""""':;ACI1EMS
1. Structu.l'alsystem including submittal and er~on of all 1. HVAC system including final test
building components (trusses. precast. metal building. e~) (ILHR 64.53)
2. Fire protection systems (sprinklers, alarms, smoke detectors.
fire extinguishers)'
3. Exits including exit and directional lights
4. Shaft and stairway enclosures
5. Fire-resistive construction, enclosure of hazards, fire walls,
labeled doors, class of construction
6. Sanitation system (toilets. sinks, drinking facilities)
7. ILHR barrier free requirements
8. All conditions of building plan approval and applicable variances
The following items are not in compliance and'must be addressed:
2. All conditions of HV AC plan approval
and applicable variances
B) 0 Statement of Noncompliance
Due to the tollowlnIJ listed VIOMOOM. thIS pr()Je(t IS not reAdy tot OCCUIMncy:
C) 0 Supervising Protessiona' Withdrawn From Project
(Use A Of 8 aOove to Inc:liute prOjeCt statui as of thIS caUl.)
Oate Withdrawn
.HV Af Supervising Protessionai
Date