HomeMy WebLinkAboutHVAC Compliance Statement - 09/16/2010 SEP -16 -10 10:46 AM CONDON TOTAL CO T 9207485034 P.01
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UILDINGS, HVAC, COMPLIANCE - 72
STATEMENT SB� 9 0
Th s 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 o greater and bleachers
(Comm 61.40). Failure to submit this form may result in penalties as specified In Comm 61.23 and/or local ordinances.
This form ,bust 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 pion approval letter for fgency address)
• Safety arid Buildings, 10541N Ranch Roa5 Hayward, WI. 54843
Note: If the review was done by the municipality, the compliance statement goes only to the municipal building
Inspector. A copy Is not needed by Safety & Buildings. •
' 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 Lsi -:309 -084 Project Name ,�h` nt�. tl
Site Number �+, -
Site locatioh (number & street) t Cr) U- MAls.) �"- a ' •6 •
: 1t,City ❑ Village ❑ Town of te.k4r) County of Q 1 tru.)tkr %Up •
2. PURPOSE OF THIS STATEMENT; (Check Box A, B, C, or D to Indicate purpose and crmplete any other
applicable boxes and information. Attach additional pages If necessary.)
Check those which apply: ❑ Building Object ID # ❑ HVAC Object ID #' .
0 Lighting Object ID #
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❑ Partial Completion '
• Description of Portion Completed .
A) Statement of Substantial Compliance
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: to the beat of my knowledge, belief, and based on onslte observation, construction of the foll win building nd/or HVAC
Remo applicable to this protect have been completed in substantial compliance with the apprcived plans and specifications.
CU BUILDINO/LIGHTING ITEMS
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f, Structural system Including submittal and erection of all building components 10. Exterior Ilghtl $ g & control requirements
• (trusses, precast, metal building, etc.) 11. Interior Ilghtln� & control requirements
2. Fke protection systems (sprinklers, alarms, smoke detectors) designed, Installed, 12, All conditions of lighting plan approval
i and tested (Including forward flow on back flow devices) by appropriately and applicable varI ncea
registered professionals
3. Shaft and stairway enclosure •
4. 'Exits Including exit and directional lights •
• 5. Fire - resistive construction, enclosure of hazards, lire walls, labeled doors, class likl.IVAC ITEMS ;
of construction, fire stopped penetrations
6. Sanitation system (toilets, sinks, drinking facilities) 1. HVAC system I luding final teat
• 7. ,Banter -free Including Comm 18 elevators and tlfta 2. All conditions HVAC plan approval and
O. • Energy envelope requirements applicable varl noes A
3. All conditions of building plan approval and applicable variances 11 4
The following Items are not In compliance and must be addressed: "'1 •
8) ❑ Statement of Noncompliance
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Due f0 the following listed violations, this protect le not ready for occupancy:
C) G ; Supervising Professional Withdrawn From Project (Uee A or B above to Indicate project status as of this date.) •
D) O , Project Abandoned
3. SUPERVISING PROFESSIONAL IGNATURE FOR: \
0 Building 1 HVAC 0 Lighting MO,— W aRITIte Dat
i Name (please print or type) (� N-414610
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Phgns numb•r`l at
Customer ID $ & 1 7O Signature 1 �►� `� ,..—�
. SBD•9720 (R.07/2008) •
SBD.9720 (R.0212004)
Received Time Sep. 16. 2010 11:34AM No. 2853