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Compliance Statement
This form is required to be submitted by the architect, engineer, or HV AC desi~ner (supervising professional)
observing construction of projects within buildings with total volumes exceeding 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 aJ!4' e~
occupancy of altered existing buildings, submitthls completed ana signeH1:if il1\to~
The municipal building inspection office and also to
DILHR, Safety and Buildings, P.O. Box 7969, Madison, WI 53707 JUV
Personally identifiable information may be used for other purposes. .~.. " 7? 1994.
1. PROJECT INFORMATION: (Use the DllHR or municipal project label, or type cfftP;~ll}t.!tl:ie'lNo~,O,l~tion.)
'Q1J'(lf.dFII,~', ,., if ('~'~'.:.}j' ,:j,'"
Owner Information ProjeCt'tnfqf",ati~~:iiii /
Name Bui lng "upancy apter s & Use '" '- III Ll.j "i.. .
Cha ter 54 Furni ture store1i:--~!,,-
Tenant Name I any
Wallace Furniture
BUI 109 Location num r & street
30u Koeller Road
the final
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COMPLIANCE STATEMENT LABEL
STORE
LANDMARK UNLlMITED PARTNERSHIP III
300 KOELLER RD
OSHKOSH
92-09-0185-8
A0004424
r\
E
1&1 City 0 Village 0 Town of
Oshkosh
Building Project I
92097
H\/AC Project I
2. PURPOSE OFTHIS STATEMENT: (Check Box.A"B, or <;to indicate purP9se and comp'lete any other applicable
boxes and InTOrmatlon. Attach additional pages If necessary.)
o Building and HVAC ~ Building Only 0 H\/AC Only
o Piutial Completion r
Description of.Portion Completed
A) ~Statement of Substantial Compliance
To the st of my knowledge. beli~f, and ba~d on on~ite obs~rvation. construction of the foll~~in~ building and/or HVAC item. .pplicable to
this pro ct have been completed In substantial compliance With the approved plans and speclflc.tlons.
~UllDING ITEMS .
1. Structural system including submittal and erection of all
uilding 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 barrierfree 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
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
VAC Supervising Profenional
Date
ng Supervising Professional
SBD-9720 (R. 01194)