HomeMy WebLinkAboutHVAC Compliance Statement
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" Buildings, HV AC, Compliance Statement APR 1 9 2005
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 50,000 cubic feet or g,. r,;a, ~fS
(Comm 50, 10fComm ~1,50). Failure to submit this form may result in penalties as specifietb"~G.Pli1i1u'frJI.f1\~ E. '. [. . [c\li"if'IM'
61.23 and/or local ordrnances. . mil!! In T .. . .. rl~Jk.J~ T
General Instructi9ns: 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 Ll:IW, s. 15.04 (1)(m)].
~;a:s:~:~~:I~:::~AJ9~ ;:S;'~;!0'ri9~itli information fiom yourp~ :~rovalletler.
Site Number ~ /a2~
Site location (number & street) .1"" ';,?C-'.f//; kA ./?/?~.?
%City 0 Viiiage .0 Tovm of7 ,-0. County of ~ . ~@~ 'LPO 0
2. PURPOSE OF THIS STATEMENT: (CllecksoxA, B,c,orb !oindicatepurpose and cornplete any other
applicable boxes and information. Attach additional pages if necessarY.),
Check those which apply: 0 Building Object ID # ~VAC Object 10 #
o Lighting Object 10 #
o Partial Completion
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Description of Portion Completed
A~ 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/LlGHTlNGITEMS
1. Structural system including submittal and erection of all building components
(trusses, precast, melal building, etc.)
2. Fire protection systems (sprinklers, alarms, smoke detectors) designed, installed~
and tested (including forward flow on back flOW devices) by appropriately regisleretl
professionals
3. Shaft and stairway enclosure
4. Exits including exit and directional lights ~
5, Fire-resistive construction, enclosure of hazards, fire walls, labeled doors, class of HVAC ITEMS
construction, fire stopped penetrations
6. Sanitation system (toilets, sinks. drinking facilities) 1. HVAC system including final test
7. Barrier-free including Comm 18 elevators and lifts 2. All conditions of HVAC plan approval and
8. Energy envelope requirements applicable variances
9. All conditions of building plan approval and applicable variances
10. Exteriorlighting & control requirements
11. Interior lighting & control requirements
12. All conditions of1ighting plan approval
and applicable variances
The following Iterns are notin compliance and must be addressed:
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B) 0 Statement of Noncompliance
Due to the following listed Yiolations, this project is not ready for occupancy:
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C) 0 Supervising Professional Withdrawn From Project (Use A ot B c:bove to indicate project status as of this date.)
D) 0 Project Abandoned
3. SUPERVISING PROFESSIONACS1GNATOREFOR:
o Building ~HVAC 0 Lighting_
Name (please print or type)
Phone numbe~J/-J ~t:J Customer lD # ~<?2;5 9 Signature
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