HomeMy WebLinkAboutCompliance Statement (HVAC) - 10/21/05)
Buildings, HVAC, Compliance Statement OCT 242005
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 0 s
(Comm 50.10/Comm 61.50). Failure to submit this form may result in penalties as speci
61.23 and/or local ordinances.
Generallnstructions: Prior to the inilial 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 Law, s. 15.04 (1)(m)].
1. PROJECT INFORMATION: Please fill in the foll~~ng wif/1 info~matio~J..°m your play ~pprovalletter.
TransactionlDNumber /' /7"/S'2'é>~c-/øaJe-((ý)).;(?-
Site Number . /' A &- F~.a jT..øe» -
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2. PURPOSE OF THIS STATEMENT: (Check Box A, B, C, or D to indicate purpose and complete any other J
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0 Lighting Object ID # ~ - JP- ¿) ð' ¿,2,£
~artial Completion
Description of Portion Compieted
A) Statement of Substantial Compliance
i 0 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.
0 BUILDING/LIGHTING ITEMS
1. Slructural system including submittal and erection of all building components
(Irusses, precasl, metal building, etc.)
2. Fire proteclion syslems (sprinklers, alanns, smoke detectors) designad, inslallad,
and teslad (including forward flow on back flow devices) by appropriale~ registerad
professionals
3. Shaft and stairway enclosure
4. Extts including exU and directional lights
5. Fire-resislive conslruclion, enclosure of hazards, flre walls, labelad doors, class of
conslruction, fire stoppad penetralions
6. Sannalion syslem (toilets, sinks, drinking facilnies)
7. Barrier-free including Comm 16 elevalors and lifls
6. Energy envelope requirements
9. All condnlons of building plan approval and applicable variances
The following Items are not In compliance and must be addressed:
10. Exterior Iighling & conlrol requirements
11. Interior lighting & conlrol requiremenls
12. All conditions of lighling plan approval
and applicable variances
~VACITEMS
1. HVAC system including final lest
2. All condilions 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 ~bove to indicate project status as of this date.)
D) 0 Pr~ectAbandoned
3. SUPERVISIN~ P FESSIONAL giG. N~ FoBiL / AJ J3 / ~ ../ ~1 &.
0 Buildin VAC 0 Lighting / ~ ........7...0/. . ~ Date £~ ()I'v/ a -zl
. Name (please prinl or type)
Phon"l'umber / Customer 10 # 9' /,?¿? ?~ Signature ~ './J4
(9cl,ç)óJ.?/-,fðc/O /'.