HomeMy WebLinkAboutBuidlingn, HVAC Compliance Statement (02/21/13) nr Safety and Buildings Division
Buildings, HVAC Compliance Statement
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 volume of 50,000 cubic feet or greater and
bleachers(SPS 361.40). Failure to submit this form may result in penalties as specified in SPS 361.23 and/or local
ordinances. This form must be submitted prior to the plan approval expiration date or another submittal may be required.
Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)].
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 plan approval letter for agency address)and Safety and Buildings Division, 10541 N 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 S&B.
1. Project Information: Please fill in the following with information from the plan approval letter.
Transaction ID Number v20IP 81 3 Project Name I CcG+4— Oare- use- 4.19441.1.
Site Number (p 5-4.52—
Site location(number&street) •155-'S �'}�Agar S
lif City ❑ Village ❑ Town of O.&L L County of (,J i runG(Oc5 t,
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: PI-Building Object ID# I (PLI S"i l ❑ HVAC Object ID#
❑Lighting Object ID#
Partial Completion WArdelctfi 5117Iq i m awS. i('e&}r ,.,s ( ,,,�p/+e PlrtVc -
Description of P&rtion Co'ifpletett t
oc$4-1+.5 bt„:141■03 re." ks.,
A) ❑ Statement of Substantial Compliance
To the best of my knowledge and belief, based on onsite observation,construction of the following building and/or HVAC
items for 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 building 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) 1. HVAC system including final test
7. Barrier-free including Comm t8 elevators and lifts 2. All conditions of HVAC plan approval and
8. Energy envelope requirements applicable variances
9. All conditions of building plan approval and applicable variances
The following items are not in compliance and must be addressed: 1,, r trz
y !• JV 6.L r44,seEL+V t2 pc- plans 2. lkgea nT eei 10.F-VS 4`ts/es 4-- "✓e444.� f
3. t iss4,11
B) ❑ Statement of Noncompliance lC toac fov,c it e.4 C 4. raga•sf
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. Supervising Professional Signature for: Ir-� i �7 I
Building ❑ HVAC ❑ Lighting Kit. �a2xC.2lGVto s ILt` Date 2 a( `2o!
--••�� Name(please print or type)
Phone number�2��v 924-`l niriCustomer ID# /oc(3"70 Signature 7
SBD-9720(811/11)