HomeMy WebLinkAbout2007-Certficiate 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:
11/28/2007
11/29/2007
BFO Factory Shoppes LLC
6250 N River Road 10400
Des Plaines IL 60018
CERTIFICATE OF OCCUPANCY
An Occupancy Permit is hereby issued for the Harry & David Outlet Store, tenant
space E-30, located at 3001 S Washburn St, Oshkosh WI as described in
Building Permit #127179.
This building shall be used as a Retail Store and is located in the M-3 General
Industrial District.
LIMITATIONS:
Maximum number of persons: 71
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 vali
cc: R & H Property Maintenance LLC
Building Permit Work Card
Job Address 3001 S WASHBURN ST Permit Number 0127179
Create Date 10f9f2007
Owner BFO FACTORY SHOPPES LLC
-,.---.-,----.--------,-...-..--
Contractor R & H PROPERTY MAINTENANCE LLC
Category ?~?__- Alt~tio~~o.r:es ~_Customer Service
Plan 25-2138-0907
Occupany Permit ~l?_9-~ire~____ Flood Plain No Height PermitJ'.lot_~~guire_d Class of Const:
Use/Nature [Space-E-30 / Ten-anCSp-aceaiteratiOilsfornew-Harry-n5aVlcfOL.JllelSfore: -----
of Work i
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HV AC Contr
Plumbing Contr
Electric Contr
Inspections:
Date 10/24/2007 :
_.._---------~~.-._- --~--
'Reques(llne
I
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Type Rou~L~____ Inspector Allyn Dannhoft_________
no time
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Date/Time requested: .!.Q~~~~2~J'J.!_ Notice Type: Ready Date/Time: ~Q125@Q!_~~~__
Access: 'o-pen--=--~- ________===-===---=-=========-====--=-=-==--=-==:==J
Requested By: !,\etail_~ns~ction - Roger ______________ Phone Number: ~12-84~-08QQ_________________
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Date l~~!~?QQ~ ~___ Type ~ough In______ Inspector Allyn J:lannl1oft_____________ no time
[REQUEST-lINE/READY FOR AN ABOVE CETIING B-lJjeblNG & HVAC INSPECTiON-Allyn - This-message wascutlinginan-a-oun---'I
Icould not make out all of what he said so you may want to call him before you go out there, sorry.
!
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_ _____...1
Date/Time requested: 11/6/2007 03:32 PM
Notice Type:
Ready Date/Time: 11f7f2007 00:00 AM
Access: ::_==_:==========-==:-:==-=_=-=--=::==-
Requested By: ~~!:~!!:.f_<2.N~TRlJ.~"!:~Q."!.~_~ge~__m_ _________ ._______ Phone Number: \6J~~4_5.:08gg
. 0 Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Date ~~!.1.?~20~_ _:....___ Type final Inspector AIlY_f!..Q~_f!.I1.()fL_______________ not approved
[REQUESfUNETwOULD L1KEFlNAL BUILDING-a;- HVACINSPECTIOr\is. Need-additio-naTemergency illumination-in exitpath rilre-tall'
,area, building and HVAC compliance statements, HVAC duct detector alarms. OK to stock store, not to open to public until i
I"'::'",~e m"e___ _____ _M___ . _____ J
Date/Time requested: !1'~~ Q.2..:.:!iJ'-""'-
Access: I
Requested By: 13_i::TAIL CONSTRl!_CTIO~- R~[ElE______ ___________ Phone Number: (61.?l.~~_5.::9_?_Q9_______.
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
:::uj~~~f~E>\~;'~~~~~~............;;~~~;';;,.~"i",",,~~......-~=~..~-=-;>~~..
1**WOULDLlKE .11/15/07 THURSDAY AFTERNOON**
I I
I_.____--_._---_._-_._---~----------_._-----_._------- -------.-..-. -. .
Notice Type:
Ready Date/Time:
11f12f200700:00
-=:=
.i
Date/Time requested:
11f14f2007 06:17 PM
Notice Type:
Ready Date/Time: 11/15/200700:00 PM
,_.~~~______._,.__~~~__~n..__.___.... __._......__.,._.__.....___________._..._____ _.
Access: i
_ _ _ _ _ _. _ _. _ _ _ ~ _ _ _ _ _ _ __ _ _ _ _ _ _ ~ ~ _ _ _ _ _ _ _ _ _ _ _ _ h ~ ~ ~ ~ _ _ _ _ _ _ _ _ _ _ _. _ _ _ _ _ _ _ _ _ _ _ ~ _ _ _ _ _ _ _.. _ _ _ _ _ _ . ~.. ~ ~ _ _ _ _ _ _ _ _ _ _ _ ~ h. _ ~ _ - _ _ _ - - - - - - - - - -. * * - -. - - - - - - - - - - - - . - ~ ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
Requested By: ~E:I6!.L_CON_~JRUc:TI()I'J__~ 13~9E:lL___
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
Phone Number: (Ei1~1?4?:0_800
Page 1 of 1
Electric Permit Work Card
Job Address 3001 S WASHBURN ST Permit Number 127265
Create Date 10/15/2007
Own~r BFO FACTORY SHOPPES LLC Contractor SUBURBAN ELECTRICAL ENGINEERIN<
Service b New . ChangeO Temp 0 N/A I Type . Overhead 0 Underground 0 N/A
Volts 120/208 Circuits 66 Luminaires
Amps 300 Switches 9 Receptacles 37
Use/Nature 643 - Commercial-Addition/Remodels Suite E30 Harry & David / Tenant build out
of Work
Value
$21,000.00
Inspections:
Date 10/24/2007 Type Rough In Inspector Kevin Benner
Request line / The front soffit has an open K.O. ,which I reviewed with the G.C. on site.
approved w/cond.
DatelTime requested: 10/23/2007 07:50 AM
Access:
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Notice Type:
Ready DatelTime: 10/24/2007
AM
Phone Number: Rob - 920-841-7070
Date 11/05/2007 Type Service Inspector Kevin Benner not approved
he 350 KCMIL CU conductors shall beproteceted with an OCPD that is appropriate for the conductor. Discussion with Rob he agreed that
hey would install a 300A Breaker at the meter.
DatelTime requested: 11/01/2007 08:10 AM
Access:
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Notice Type:
Ready Date/Time: 11/05/2007 00:00 AM
Phone Number: 920-841-7070 Rob
Type Re Service
Inspector Kevin Benner
not approved
Date 11/06/2007
Bonding jumper is required to be #2 cu, the installed is a #4 cu
he electrician stated the MCB is factory set @ 298 Amps. The settings are: 10 10.8, longtime .93, short time 6. MCB is Sq.D DJM 32400
E20. Conductor size is 350 KCMIL cu
Date/Time requested: 11/05/2007 02:20 PM
Access:
Notice Type:
Ready DatelTime: 11/05/200702:20 PM
Requested by: SUBURBAN ELECTRICAL ENGINEERING
Phone Number: 841-7070 Rob
o Reinspect Fee 0 Fee Wavied
o Reinspect Fee Paid
Date 11/07/2007 Type Abv Ceiling
r;'" Roo"ea' I S'me .,eo O"~
Date/Time requested: 11/06/2007 00:00 AM
Access:
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Inspector Kevin Benner
approved
Notice Type:
Ready Date/Time: 11/07/2007 00:00 AM
Phone Number: 841-7070 rob
to;.. Electric Permit Work Card
Job Address 3001 S WASHBURN ST Permit Number 127265
Owner BFO FACTORY SHOPPES LLC
Service b New . ChangeO Temp
Volts 120/208 Circuits
Amps 300 Switches
ON/A
66
9
Create Date 10/15/2007
Contractor SUBURBAN ELECTRICAL ENGINEERIN(
I Type . Overhead 0 Underground 0 N/A
Luminaires
$21,000.00
Value
Receptacles
37
Use/Nature 643 - Commercial-Addition/Remodels Suite E30 Harry & David / Tenant build out
of Work
Inspections:
Date 11/07/2007
Type Re Service
approved w/cond.
Inspector Kevin Benner
'Field Request
APPROVED TO ENERGIZE / Faxed to WPS 11/7/7 PM
!Physical Protection is to be provided for the distribution & metering equipment. The meter & disconnect is to be identified as to its purpose.
Reviewed with Rob form the E.C.
DatelTime requested: 11/06/2007 00:00 AM
Access:
Notice Type: FC Ready DatelTime: 11/07/200700:00 AM
Requested by: SUBURBAN ELECTRICAL ENGINEERING
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Date 11/08/2007 Type Abv Ceiling
IFleld R..,es' I Sa,' Rooms I Not Resdy
Date/Time requested: 11/07/2007 11 :58 AM
Access:
Phone Number: 841-7070 Rob
Inspector Kevin Benner
not approved
Notice Type:
Ready Date/Time: 11/08/200700:00 PM
Phone Number: 841-7070 Rob
o Reinspect Fee 0 Fee Wavied
Requested by: SUBURBAN ELECTRICAL ENGINEERING
Date 11/12/2007
Type Final
o Reinspect Fee Paid
not approved
Inspector Kevin Benner
REQUEST LINE / READY FOR A FINAL INSPECTION
*Would like the inspection sometime Monday (11/12/07)** /In addition to the FCN the following vio.'s were reviewed with Rob: Disconnects
or the sign & freezer, seal penetrations in the cooler & freezer, op
3n j-box over the freezer, convection oven rec. was not installed, panel covers & id OCPD's.
Date/Time requested: 11/09/2007 01 :53 PM
Access: Call Rob McHugh at (920) 841-7070
Requested by: SUBURBAN ELECTRICAL ENGINEERING Phone Number: (920) 841-7070 Rob McHugh
o Reinspect Fee 0 Fee Wavied D. Reinspect Fee Paid
__. _.........n...... nn.... ____... .n.... nn~. ______... ____.... nn.. ..n" nn. n n... nn. .n.... n... n'n. o....o... no... n.....__...__..
"""R" ~11!1l!i.. .
Date 11/15/2007 Type e Ina _."- Inspector KeVin Benner ~-w/_cond.
~. "'~"""
REQUEST LINE / READY FOR A FINAL REINSPECTION
Physical protection shall be provided by the owner for the electric service equipment located outside. Incorrect breaker locks were installed
1F0r the freezed & the sign. I called the electrician while I was on site. He stated he wiould correct immediately. he called 11/15/7 @ 3:41 PM
land stated the correct locks are now installed.
Notice Type: FC
Ready DatelTime:
11/12/2007 00:00
OJ;
Date/Time requested: 11/14/2007 06:17 PM
Access:
Requested by: Retail Construction - Roger
o Reinspect Fee 0 Fee Wavied 0 Reinspect Fee Paid
Notice Type:
Ready Date/Time: 11/15/2007 00:00 PM
Phone Number: (612) 845-0800
~
-=-
1~/15/2007 12:23
,-
'.>-'
9202318915
~
!~,Outlet
Sh6ppes at Oshkosh
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VIA FACSIMILE
Date: November 15, 2007
To:
Allyn Dannhoff - City of Oshkosh
236-5084
Fax No.:
From:
Phone:
Fax No:
Ema":
Address:
Keith Holschbach
920-231-4561
920-231-8915
Oshkosh@horizongroup.com
3001 S. Washburn St. Ste 801
Oshkosh, WI
Number of Pages, including cover page: 1
Allyn,
PAGE 01/01
HGP~
Horizon Group Properties
Griese Construction will be installing the protection at the electrical panels by
Harry & David the week of 11/19. Feel free to call me with any questions.
Thank You
Keith
CONFIDENTIALITY NOTICE:
This communication is intended only for the use of the intended recipient(s)
named above and may contain information that is privileged and confidential. If
you are not the intended recipient, you are hereby notified that any dissemination
of this communication or the information contained herein, or the taking of any
action in error, please notify us immediately. Thank You.
HVAC Permit Work Card
Job Address 3001 S WASHBURN ST
Permit Number
Create Date 10/15/2007
--"~-
Contractor BAUMGART MECHANICAL INC
127385
Owner
BFO FACTORY SHOPPES LLC
-..------------
Fuel ~[~a~::=J IT9~_ J D_~eCt~ IT~~T~T] U_~o[a! Value__~_~,~_~Qgo
System 0__Ne~______..J rrl3~J>~9_e____ _ _ ___________J Other I
~ Forced Air ORadia~-:J [JSteam----; D--A7c-------i [Ive-nr------i
--------~---------------- _______________________J ____________n_________ __ _ _________ __ _________ ____~
D_~~~~c____=_-l U_ti~I"YY~~r _J DS.~P2I~~~~~=:J O=~~~~lTr~~__:
Chimney Type tL~6]ili~lE_==_O_~h~=~eyB=~~~~~~---QQi~cTY~~C=-===:' _~~Epe!I~~Ie~____:
Use/Nature IE36 HarrY;nfavid -nnstaif2RTU's--:---------- - - ---------------------------------------------- ------
of Work I
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Inspections:
Date 11/12/?.o.9.?_ Type Final Inspector ~!IyIl...Dan~~9!!________________ not approved
E -----------------------------------------------~
Need additional emergency illumination in exit path in retail area, building & HVAC compliance statements, HVAC duct detector alar_ms- '_
OK to stock store, not to open to public until corrections are made_ _ i
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Date/Time requested: Notice Type: ________ Ready Date/Time:
Access: [~=~---
Requested By: Phone Number:
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
--~~-;~-[';;;~~O;~;)~~...........;~~~;;;;;~~~;~~;;~~=....~.~:J..............~~~.~~..~____
i
----------------- --------------------------___________________________ _____________1
Date/Time requested: _____ ___n____ Notice Type: __n_______ Ready DatelTime: :
1-------------- _________n.______________________________==_,="=_=_~_==-~~="=_~____I
Access: L__________________________ __________ _j
Requested By: _____________ Phone Number: __________
o Reinspect Fee 0 Fee Waived 0 Reinspect Fee Paid
"1
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Job Address 3001 S WASHBURN ST
Owner BFO FACTORY SHOPPES LLC
Category 440 - Industrial-Interior
Bathtub Shower
Whirlpool Floor Drain
Lavatory 2 Lndry Tray
Toilet 2 Disposal
Res. Sink Dishwasher
Bar Sink Sump Pump
Water Heater Classrm Sink
Site Drain Breakrm Sink
Roof Drain Ejector/Grind
Misc.
Fixtures
Plumbing Permit Work Card
Permit Number .117378__
Contractor BAUMGART PLUMBING
Plan
Water Softner Wait. St. Shamp Sink
Local Waste Ice Chest FlrlWst Sink
Clothes Wshr Exam Sink Catch Basin
Bidet Sculry Sink Wash Ftn
Beer Tap Hand Sink Urinal
Lab Sink Plaster Sink Standp Rec
Sterilizer Surgeons Sink Ice Maker
Dip Well F Prep Sink Gar Drain
Drink Ftn Serv Sink Soda Disp
UsefNature
of Work
~enan-t space E 030, Harry & David. Interiorplumbing with electric water heater.
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Size
Sanitary Sewer
Storm Sewer
Water Service
Material
Type
#
Conn.Type
Create Date 10/17/2007
Value $8,OOO.0~
Coffee Maker
Int Grease Trap
Ext Grease Trap
RPZ Valve
Eye Wash Statn
Wtr Sewer Mtrs
Deduct Meters
Wtr Usage Mtrs
---I
Inspections for Work Card 94818
Date ~ 0/2~/?9_q~_ Type !.l':l~~g~und________ Inspector f=>_Olu}II'I,'c:J.lf___________u_____________ approved w/cond.
Fioorsink nof insfallecfand cleanout required for 3" building draTn.Spok-e to-pTlJmberonsite-:--------------------------------n_un_______________
Date/Time requested: 10/23/~~1g~_ Notice Type: Telephone Number: _________________~__
Access: [=~~----- --=====--====-:--=--=-------_u==:=--=-==_=====~-_J
Ready Date/Time: ~/23/200~ ~1 0 P~ Requested By:~~UM~!,-_~T P'=-LJ~_~!~~_______________
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
*----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Date 10/25/2007 Type Rough In
Inspector Pau.~Wolf
approved w/cond.
[Lavatory drain and water not finished at time of inspection. Overhead work not completed at time of inspection. Will need to see at final.
---l
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Date/Time requested:
Access:
1 0/25/200~07: 33 AM
Notice Type:
Telephone Number:
Ready Date/Time: 10/2~~g9~ 9J:3~JI.!'\I1u_ Requested By: BAUMGART PLUMBING
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -.. - - - - - - - -. - - -.. - - - - - - - - - - - - - ~ - - - - - - - - - - -. - -. - - - - - - - - - - - - -. - - - - -.
Date 11/13/2007
Type Final ___ Inspector Pa_ulWoIf ________ not approved
WatersuppIYto'hand sink in kitchen area does not work. Left"notice on site
l.._.._~.,____,____+__,.___
----------..'-'-'-~____~____'__c.........._,_...o....._._.._"__~__'_,_.._..__..__"__-'-.~.~'_,~"'--,_,___
... .__.1
Date/Time requested: 11/9/200711 :15 AM Notice Type: Fe Telephone Number:
Access: [-=~_
Ready Date/Time: 11/9/2007 11:15 AM Requested By: BAUMGART PLUMBING - Judy
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
920-788-9983
Date 11/28/2007
- -------.-.-'------------.------.---------------.-.-------------------.----.-------.-------------.------.---------.-.---------------.-----------'--.--,-
Inspector ,=-a_u~~
'H"ilndsrnk re-paired.--
Date/Time requested:
Access: r--
L '._,.___~,_____
11/29/200~08:38 AM
Notice Type:
Telephone Number:
.._,._'_._.._-----_..,---------_._----_._--_..._-_._-~--'---_._-~_._---.'-~,--'-'-_._----"-------~,...,-'-~.-~_.._--_._--_._~
_..J
Ready DatelTime: ~_1i.?.~200~ 08~~_ILAM _ Requested By: BAUrvl_(3ART P'=-LJ!'\I1.~~(3__
o Reinspect Fee 0 Fee Waived D Reinspect Fee Paid
---.----------.-.-----..--------------.-...------------------'--.----..------------------------.--------------------....-------------.--------------------------------------..--------.-------..------
.l,
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OJH<.OfH
City of Oshkosh
Division of Inspection Services
215 Church Avenue .
PO Box 1130
Oshkosh WI 54903-1130
www.ci.oshkosh.wi.us
ON THE WATER
October 9, 2007
Rod Burnett
Cubellis
281 Summer Street
BostonMA 02210
Don Penn
Don Penn Consulting Engineer
635 Westport Pkwy Ste 300
Grapevine TX 76051
Dave Spring
Horizon Group
5000 Hakes Srive
Muskegon, MI 49441
David Farrington
Cubellis
2075 Silas Deane Hwy
Rocky Hill CT 06067
Site: Plan Number: Z5-2138-0907
Harry & David
3001 S WashburnStSpace E30
Oshkosh WI 54904
For:
Description: Tenant space alterations
Object Type: Building and BY AC
Class of Construction: DB - 2984 Sq Ft.; . sprinkIered
Occupancy: M: Mercantile I Retail
Maximum No of Occupants: 71
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
Note: These plans are approved based on additional information submitted viaemail which included revisions to
sheets A.2, MI.1, M2.1,P1.1.
Key Item(s) I Conditions:
. mc 901.2 Fire protection systems shall be installed, repaired, operated and maintained in accordance with
this code and the international flIe code. Construction of new walls may require the addition and or
relocation of sprinkler heads to maintain required coverage, and not obstruct spray patterns of.fire
sprinklers, the interior of the cooler andfreezer are required to be sprinklered as well.
. 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
requirementsofIBC 1003.2.11.3. Depending on configuration of store displays and racking additional
emergency illumination may be required to comply with these requirements.
. mc 1209.1 Provide toilet room floors with smooth, hard, nonabsorbent surface extending minimum 6
inches up onto walls. Finish schedule on sheet A.S indicates 4 inch high coved - please revise to
required 6 inches. .
.. COMM62.1109 (12) Where counters are provided for sales or distribution of goods or services, at least
one of each type provided shall be accessible.
Flnspectiuns\Plan Review\Cummerdal.Hm Review 2007\Z5-2138-09D7 30(H S \Va;;hburnS, Space E30 Bidg ~)d HVAC.dot:
Page 1 of2
f
. 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
Comm 61.31(1).
SUBMIT:
. IECC 503.3.3.7 [Comm 63.0503(2)(f)] Balancing and documentation of the HV AC system shall conform
to the IMe. Balancing report required to be submitted prior to fmal occupancy being allowed.
. 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.
A copy of the approved plans; specifications, and this letter shall be on-site during construction. All pennits 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),nothingin 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 orthe address on this letterhead.
B an oe
Building Systems Consultant
(920) 236-5051 Monday - Friday 7:30 A.M. to 8:30 A.Mand 12:30 A.M to 1:30 P.M.
bnoe@cLoshkosh.wi.us
cc: Property :file
Fee Required $
Fee Received $
Balance Due $
590.00
590.00
0.00
FIJl$]Jections\Pbn RlOvit;w\Commercial PI,m Rt;,>,.,t;w 2007\Z5-2138-0907 3001 S Washburn Sl Space E30 nJdg and nVACdoc
Page 2 of2
NOV.16'2007 11:40 651 704 9100
RETAIL CONSTRUCTION SERVICES INC #5151 P.002/002
BUILDINGS, HV AC, COMPLIANCE STATEMENT SBD-9720
This form is required to be suhmitted by the supervising professional (arcl1itect. engineer. HVAC designer or electrical
designer) observing construction of projects within buildings with totel areas 50,000 cubic feel or greater Md bleachers
(Comm 50.1Q/Cornm 61.50). Failure to submit this form may result in p@ni!llties as specified in Comm SO.26/Comm 61.23
and/or local ordinances. This form must be submitted prior to the plan approval expiration date or .1I1other submittal mOlY
be required
General Instructions: Prior to the initial occupancy of new buildings or additions and the final occupanoy of
altered existing buildings, submit this completed and signed form to:
. The municipal building Inspection office (refer to the plan approval letter for agency address and
· Safety and Buildings. 10541N Ranch Road Hayward, Wi. 54843
Note: If the review was done by the municipality. the compliance statement goes only to the municipal building
inspector. A copy is not neaded by Safety & Buildings.
f:>et$Oflsl information YDuprOVide may be used for secondary purpoBes [Privacy law. s. 15.04 (1)(m)).
1. PROJECT INFORMAnON: Please fill In the following with information from your plan apprcvalletler.
. TransactiOl'\ ID Number ZS - ZI ~e.- O~cn Project Name~~...vi.d
Site Number
Site location (number 8. street) ,300 I ~ w;;,!1.hkt,lC"1'I ~+. Sf:'AcE. E,:?>O
~ City 0 VIII~ge CI Town of Qs~ KOSH County of
2. PURPOSE OF THIS STATEMENT: (Check Box A, B, C. or 0 to Indicate purpOse and complete any other
applicable boxes elnd information. Altl$lCh additional ~ges if necessary.)
Check those which apply: 0 Building Object 10 # 0 HVAC Object ID,.
o Lighting Object 10 #
o Partial Completion
Description of Ponion Completed
A) ~ Statement of SubstantIal Compliance .
To the best of my knowledge, belief. and based on on Site observation. construction of the following bulldlng and/or HVAC
Items applicable 10 Ihls prO,lect have been completed in substantial comp6ance with the approved plans and
.....)pecificalions,
Jl!l. BUILDING/LIGHTING ITEMS
1. Structural $ystem inCludlng ~ubmitta' and erection or.:111 bulklinll COmPOMnts
(11\l$$e$, precast. melSl buIlding. eto.)
2 Fire pro\e~lion sy$tem9 (9pr1nkle~, sl.'lrn\s, smoke dale<:l.or9) de$lgoed,
InlllDlleO. ant1te9teo (including forward flow On back now t1evlce!':) by
:lppfoprlatety regl9lered professionals
:'I. S~afl and 9tairway enclosuro
4. El!;its inchx:llng e:dl ;!Ind direetionalllghl,
~. ~1l'Q-re!liallve oo~tl'\lction. enclOsure or he:i:l;Irds, (,1'1 wolls. lal>l!llad <<00('9, cls'5I!I 0 HVAC ITEMS
or con9lrvctlon, fire Slopped pen~r8tJ0n5
8. Sanitation sYGtem (toilet$, !lInks, drlnklng faClIIUet)
., Bllrrler.f(" inCluding Comm 1 a elevalol'$ alld Ii!\g
5 energYerJvl!IloPl! requirements
9 ^" eo"Cl~ions Dr bulldlfl9 pl:)n apPf'O~1 an<! applicable V~riBI1CM
The following items arc not ;n COrt1plilln<;lil and must be addressed:
10. ExletlOr li~hllng 8. control requllllmenl$
11. InterIOr Ilglrting & conlrtll requiM!lml!lI1t!l
12. All exlndltlons ()f IIghlint) plan approval
and llppltcablll VBrian~
1. HVAC system Il'Idudln; final test
2. An condition! of HVAC plen approvalsnd
applicable variance'>
8) 0 Statemont of Noncompliance
Due \0 lhe following illite<! \Iio'~t1ons. Ihlt. proj9d Is not ready ror occupancy:
C) I:l Supervising Pl'ofc$$lonal Withdrawn From Project (use A Dr B above 10 indlCllte projeQt $U1tlr.llt$ oftl'lls date.)
D) CI Project Abandoned
3. SUPERVISING PROFESSIONAL 51GNATURE FOR:
~\l"Clil'l9 0 HVAC 0 lighting .....R.oO,..,&y PJuM...N61"7 D~e NI'I,
Name (pJeaM print o,~) 0 ~
PhOM nllmbar.lt1:l ,. 3 ""~\lstomer 10 # Signel"r8 ~. 'L-JI.. -
IS, .1101
~
SUD-9no (IUJ,j/2Vt>~ I