HomeMy WebLinkAboutWI depart of commerce/self-certification form to receive fire depart duescommercemi Muni ID: 70266
FDID: 70030
iscol r mmerc e Safety ildings Division Fire Prevention Program
Department of P. O. Box 7839
R y Zo�g Madison, Wisconsin 53707 -7839
TTY: Contact Through Relay
February 27 2009 Jim Doyle, Governor
TV U �� Richard J. Leinenkugel, Secretary
C
Self- Certification Form to Receive Fire Department Dues
Under s. 101.575, Stats., Wisconsin cities, villages and towns maintaining a fire department, or
contracting for fire safety services which substantially comply with certain statutes are entitled to a
proportionate share of monies collected through the state Fire Department Dues program, under s.
101.573 and 601.93, Stats.
For the Wisconsin Department of Commerce to make a determination of substantial compliance for
calendar year 2008, the following self- certification form must be completed, signed, and returned to the
department by April 1, 2009, as established in s. 101.575(4)2., Stats., and as established in s. Comm
14.48(3)(a) -(c), Wis. Admin. Code.
Some municipalities are served by only one fire department, while others receive fire safety services from
more than one fire department. Therefore, a municipality may receive multiple copies of these forms due
to the multiple fire departments involved.
This self- certification is divided into two sections of questions to document the situation in each
municipality and to allow the fire chief to specifically certify for the services. Section A addresses fire
protection services and Section B addresses fire prevention services. All three pages of this form must be
returned, including this first page Please make copies for your records.
An explanation of this form is attached to help in providing the correct information for your particular
circumstance. A Fire Prevention Coordinator districts map is included in this packet so the S &B
coordinator may be contacted if there are questions about the Fire Department Dues Program or this
form.
This form is for fire safety services that the OSHKOSH FIRE DEPT 70030
provided in calendar year 2008 for the: CITY OF OSHKOSH 70266
• If services were for both fire protection and fire prevention, then complete
Sections A and B of the form and check this box:
OR
• If services were for fire protection only, then complete Section A on page two
of the form and check this box:
OR
• if services were for fire prevention only, then complete Section B on page
three of the form and check this box: El
Both the clerk and the chief of the fire department providing fire safety services to the city, village or
town must sign and date the appropriate signature line(s) of this self - certification form. If the name of
the person signing is different than the name provided from our records (as preprinted in the signature
sections of pages two and three of this form), print the full name of the person signing this year's form in
the shaded space provided. A return envelope is provided for your use. If it is not in your
envelope, please send the form(s) to the address in the letterhead above.
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Muni ID: 70266
FDID: 70030
Section B: Fire Prevention Services
Under s. Comm 14.48 (3) fc) the fire chief of every city, village, and town must certify whether or not they are
in substantial compliance with the following requirements. Place an X in the box below by the correct
answer. Choose only one answer.
The chief of the fire department provides for the inspection of every public building and place
of employment at least once in each non - overlapping 6 -month period, or in accordance with
the exceptions established in s. Comm 14.47 (2) (d) 2.a. -r., Wis. Admin. Code, or in
accordance with a special order issued by the Department of Commerce, in all territory
served by the fire department. Required by s. 101.14 (2) (c) 1., Stats.
Written or electronic reports of fire inspections are made and kept on file by the local
authority having jurisdiction to conduct inspections, or its designee, in the manner and form
required by the department. Required by s. 101,14 (2) (e), Stats.
• The fire department provides public fire education services. Required by s. 101.14 (2) (cm),
Stats.
Was the subject fire department insubstantial compliance with the regulations in Section B? Yes M No ❑
I, the undersigned, hereby certify that the answer indicated for Section B of the self - certification form is true. 1 am signing this document in my
capacity as the fire chief for: OSHKOSH FIRE DEPT FDID: 70030
Pav status: 1
Chief name:' TIMOTHY FRANZ
FD Phone: (920) 236- 1 Alternate Phone: (920) 236 -5235
Email address: tfranz @ci.oshkosh.wi.us
W# I Fire chief signatur
Personal information you provide may be
Date: ? — 2 f,.. 0'5'
secondary purposes [Privacy Law, s.15.04 (1)(m), Stats.]
'Substantial Compliance, as defined i s. Comm 14.02 (10) and for the purposes of s. 101.575 (4) (a)
1. and 2., Stats., means an ample amount of the required activity was performed through a concerted
effort aimed at total compliance. A determination of substantial compliance is obtained through a
common -sense approach to evaluating whether enough effort was made to comply with the applicable
statute or code requirements. Substantial compliance is not a specific number or percent of compliance.
A determination of substantial compliance in any one year or regulatory standard does not mean that the
same amount of compliance or effort in the following year or in another area of the code automatically
equals substantial compliance.
Questions about this form may be directed to Safety and Buildings Division Fire Prevention Coordinators; see map
coordinators' districts. The clerk and the fire chief should each make a copy of all three pages of this self -
certification form for their records.
SBD 10318 (R. 02/09)
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