HomeMy WebLinkAboutCompliance Statement (Bldg & HVAC) - 12/14/2004 Dec.14. 2004 10:01AM No.2391 P. 2/2
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 Ea
• Safety and Buildings, 10541N Ranch Road 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 8 Buildings.
Personal information you provide may be used for secondary purposes [Pfivacy Law, s. 15.04 (lXm)I.
1. PROJECT INFORMATION: Please fill in the following with information from your plan approval letter.
Transaction ID Number 1024487
Site Number 169704
Site location (number & street) 340 S. Koehler Road
X City D Village O Town of Oshkosh County of Winnetao
2. PURPOSE 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: X Budding Object ID # 971598 X HVAC Object 1D # 971601
17 Lighting Object ID it
0 Partial Completion
Description of Portion Completed
A) X Statement of Substantial Compliance
To the best of my knowledge, belief, and based on omits 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.
X BUILDINGIUGHTING ITEMS
1. Stnrcfixsl system including submittal and erection of all building components 10. Extsdor fighting 1 control requkameM$
(trusses, precast, metal building. etc.) 11. Interior fighting a control requirements
2. Fire protection systems (sprinklers, -damn. smoke detectors) designed, 12. All conditions of lighting pion approval
installed. and tested (including forward flow on back flow devices) by and appNcable variances
approprlatey registered professionals
3. Shaft and stairway enclosure
4. Exits including exit and directional tights
S. Fide - resistive construction, enclosure of hazards, fire walls, libeled doors, class Or HVAC ITEMS
of ' n, fire stopped penetrations
6. Sa system (toilets, sinks, drinking facilities) 1, HVAC system including final test
7. ' - including Comm 18 elevators and Hite 2. M conditions of HVAC plan approval and
9 E envelope requirements applicable variance
il. AN dions of building plan approval and applicable variances
The fo ing items are not in compliance and must be addressed:
8 ) 0 n t of Noncompliance
Due to f oll ow ing listed violations. this project is not ready for occupancy:
C) 0 Supervising Professional Withdrawn From Project (uae A or B above to indicate project status as of this date.)
D) ❑ Project Abandoned
3. SUPERVISING PROFESSIONAL SIGNATURE FOR:
X Building X HVAC O Lighting Jeffrey M. Stowe December 14.2004
Name (please orbit or type) II,'Ii
Phone number 414/2784760 Customer ID a Awn Signature f ii)1( 4
SBD -9720 (R.02/2004)