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Compliance Statement
This form is required to be submitted by the architect, engineer, or HVAC desisner (supervising professional)
observing construction of projects within buildings with total volumes exceedmg 50,000 cubic feet and construction
of antennas, towers and bleachers (lLHR 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 and signeg,;~qs01 . M, '
The municipal building inspection office and also to n~~ i.":~ I
DILHR, Safety and Buildings, P.O. Box 7969, Madison, WI 53707 <, ....... ,
Personally identifiable information may be used for other purposes. , . (~ ,c: 0 I 9 1994-
1. PROJECT INFORMATION: (Use the DllHR or municipal project label, or type or print the infurmation.)
Owner Information Project Infor",,~iQ1).;'Tf;G i.
,~" ~".", t'" ~ ~ t ,I if ~ t.
Bui ing Occupancy C apter s &.U~} Vi; ~
h t'ai~t"
Tena C!;;l ~ all: A
BUI
300 Koeller
IZI City 0 Village
RETAIL
LANDMARK UNLIMITED PARTNERSHIP III
SHELL & SUITE 1 &
300 .~LLER ROAD
(ISHKClSH
94-03-0046-B
A0004424
E Name an
PHASE II
of
Oshkosh
Name
COMPLIANCE STATEMENT LABEL
Building Project #
94012
HVAC Project #
2. PURPOSE OF THIS STATEMENT: (Check Box At,B, orCto indicate purpose and comp'lete any other applicable
boxes and imormation. Attach additional pages If necessary.)
o Building and HVAC ~g Only 0 HVAC Only
o Partial Completion
Description of,Portion Completed ". ... .
A) ~tement of Substantial Compliance
To th~S;O~~y knowledge. belief, and based on on site 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.
~iLDING 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 and installed by appropriately registered professionals
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:
o HVACITEMS
1. . HV AC system including final test
(ILHR 64.53)
2. All conditions of HVAC plan approval
and applicable variances
vt0- ~ 'fk
r~~
- ~
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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.)
Date Withdrawn
D) 0 Abandoned
~ATU:~~: _
Building Supervising Professional
SBD.9720 (R. 01194)
'11%14, CS "f' I
. Date HVA upervlslOg Pro eSSlona
Date