HomeMy WebLinkAbout2000-Compliance Statement (building) Buildings,IPOWSKVINIVCompliance Statement
This form is required to be submittediby the supervising professional (architect, engineer, HVAC designer or electrical
designer) observing construction of projects within buildings with total areas 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 buildings or additions and the final occupancy of
altered existing buildings, submit this completed and signed form to:
• The municipal building inspection office and -
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 & I – 2. - - O V e t J C T/2.6%3.5 - F s g — r C 2 D r 4MI 04
Site Number — _ r C am -.
S' a location (number & street) 2� mil- if- / �,
City �illlilfifi■JI� *lam & f115 4 County of l�c00E v
. PURPbSE OF THIS STATEMENT: (Check Box A, B, C, or D to indicate purpose and complete any other
applicable boxes and information. Attach additional pages if necessary.)
Check those which apply: Building Object ID #
❑ Partial Completion --
Description of Portion Completed
A)
Statement of Substantial Compliance
A/ ` To the best of my knowledge, belief, and based on onsite observation, construction of the following building and /or HVAC
item pplicable to this project have been completed in substantial compliance with the approved plans and
s ifications.
BUILDING ITEMS 0 HVAC ITEMS
St ructural system including submittal and erection of all building 1. HVAC system including final test
components (trusses, precast, metal building, etc.) (ILHR 64.53)
2. Fire protection systems (sprinklers, alarms, smoke detectors) designed, 2. All conditions of HVAC plan approval and
installed, and tested (including forward flow on back flow devices) by applicable variances
appropriately registered professionals
3. Shaft and stairway enclosure ❑ LIGHTING ITEMS
4. Exits including exit and directional lights 1. Exterior lighting & control requirements
5. Fire - resistive construction, enclosure of hazards, fire walls, labeled 2. Interior lighting & control requirements
doors, class of construction 3. All conditions of lighting plan approval and
6. Sanitation system (toilets, sinks, drinking facilities) applicable variances
7. Barrier -free including Comm 18 elevators and lifts
8. ILHR 63 energy envelope
9. All conditions of building plan approval and applicable variances /�
The following items are not in compliance and must be addressed: L� 1 Zs // r E !,JsmitLD
11 b ..er , . ( El_ (r Chi 1 5 /►� 15S 1..) 4 0, IN.. r+l .P. u) - /r -R0
B) ❑ Statement of Noncompliance
Due to the following listed violations, this project is not ready for occupancy:
C) ❑ Supervising Professional Withdrawn From Project (Use A or B above to indicate project status as of this date.)
D) ❑ Project Abandoned
3. SUP SING PROFESSIONAL SI ATAT - -- /.
Building C �' E/ "-Va- "" i Date I 5 f
Name (please print or type) j
Phone number 'ON Customer ID # Signatur. � ii� _—
4111114
SBD -9720 (R.05 /98)
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