HomeMy WebLinkAbout2010-Compliance Statement (building) BUILDINGS, HVAC, COMPLIANCE STATEMENT SBD -9720
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 greater and bleachers
(Comm 50.10 /Comm 61.50). Failure to submit this form may result in penalties as specified in Comm 50.26 /Comm 61.23
and /or local ordinances. This form must be submitted prior to the plan approval expiration date or another submittal may
be required.
General Instructions: 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 (refer to the lan a
• Safety and Buildings, 10541N Ranch Road Hayward, P approval letter for agency address and
n c Note: If the review was done by the municipality, the compliance st e goes only to the municipal buildin
inspector. A copy is not needed by Safety & Buildings. 9
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].
1. PROJECT INFORMATION: Please fill in the following with information from your plan approval letter.
Transaction ID Number r f j aa f ef'roject Name
Site Number (c0-4 = ;�4 1
Site location (number & street) ( 61 1\e" z . //-,
City ❑ Village ❑ Town of '
County of
2. PURPOSE OF THIS STATEMENT: (Check Box A, B, C, or D to indicate u —
applicable boxes and information. Attach additional pages if necessary.) p rpose and complete any other
Check those which apply: a Building Object ID # 11(
❑ HVAC Object ID #
❑ Lighting Object ID #
0 Partial Completion
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
BUILDING /LIGHTING ITEMS
1 Structural system including submittal and erection of all budding components 10. Exterior lighting & control requirements
(trusses, precast, metal building, etc.)
11. Interior lighting & control requirements
2 Fire protection systems (sprinklers, alarms, smoke detectors) designed, installed, 12. All conditions of lighting plan approval
and tested (including forward flow on back flow devices) by appropriately and applicable variances
registered 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 ❑ HVAC ITEMS
of construction, fire stopped penetrations
6. Sanitation system (toilets, sinks, drinking facilities)
7. Barrier -free including Comm 18 elevators and lifts 1. HVAC system including final test
8. Energy envelope requirements s. PGr and
9. At conditions of building plan approval and applicable variances f
The following items are not in compliance and must be addressed:
i 1
B) 0 Statement of Noncompliance M . `
CO[' DEVELOPMENT
Due to the following listed violations, this project is not ready for occupancy:
C) ❑ Supervising Professional Withdrawn From Project (Use A or 8 above to indicate project status as of this date.
D) 0 Project Abandoned )
3. SUPERVISING PROFESSIONAL SIGNATURE FOR:
1§§,, Building 0 HVAC ❑Lighting
QA� 9rAO
// Name (please print or type) Date / '-
Phone number `f 1,;�(;.) (4 tf u l
stomer ID # c� t (t . // %� j
Signature � /`r '
if )-9720 i R b4 2005,
C C ( ,