HomeMy WebLinkAboutBuilding Compliance Statement - 6/10/1996~.
Compliance Statement
This form is required to be submitted by the architect, engineer, or HVAC designer (supervising professional)
observing construction of projects within buildings with total volumes exceeding 50,000 cubic feet 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 buildinggs or additions and the final
occupancy of altered existing buildings, submitthls completed andsigned form to:
The municipal building inspection office and also to
DILHR, Safety and Buildings, P.O. Box 7969, Madison, WI 53707
Personally identifiable information may be used for other purposes.
1. PROJECT INFORMATION: (Use the DILHR or municipal project label, or type or print the information.)
Owner Information ~ Project Information
ha ter 54 Office
C#7FrtPl_IAPECE 8TliTEI+~ENT LAfiEL Tenant Name i any
C~'~TIJE Office of Parole & Probation
I.QAff~lFtf: UPdLIMITED PAFtTNER~EfIP DTI Buy in Location num r street
C~~ ~ ~ F,AF~~L.E ~ pp 3 ~0 Koel ler Road
344 b~DELLEI'c ftC~ ®City ^ Village . ^ Town of Oshkosh
i.~,sF#14C~ii County o
33-14-4i5T-B Winnebago
AO4~+~g2q Property I ent~ ication Num er
~• 6-$77
E Name an Registration Num r o t e Bui in 5 pervising Pro essiona Building Project ~
James E. Larson,A- 4~L~ 93079
Name an Registration Num er o t e HVAC Supervising Pro essiona HVAC Project ~
2. PURPOSE OF THIS STATEMENT: Check Box A B, or C to indicate purpose and complete any other applicable
oxes and information. Attach additional. pages tf necessary.)
^ Building and HVAC wilding Only ^HVAC Only
^ Partial Completion
Description of Portion Completed
A) ~#"atement 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.
DING ITEMS p HVAC ITEMS
1. Structural system including submittal and erection of all 1. HVAC system including final test
building components (trusses, precast, metal building, etc.) (ILHR 64.53)
2. Fire protection systems (sprinklers, alarms, smoke detectors)
designed and installed by appropriately registered professionals
3. Exits including exit and directional lights 2. All conditions of HVAC plan approval
4. Shaft and stairway enclosures and applicable variances
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:
B) ^ Statement of Noncompliance
Due to the following listed violations, this project is not ready for occupancy:
C) ^ Supervising Professional Withdrawn From Project' Date Withdrawn
(Use A or B above to indicate project status as of this date.)
D) ^ Abandoned
SIGNATURES:
G•/G~i~
tsuuair~g ~upervis~ng rroress~ona~ uate r+vac superns~ng
SBD-9720 (R. 01194)