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This form is �equired to be submitted by the architect, engineer, or HVAC desi�ner (supervising professional)
observing construction of projects within buildings with total volumes exceeding 50,000 cubic feet and construction
of antennas, towers and bleachers (ILHR 50.10). Failure to submitthis 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, submitthis completed andsigned fQrmPto: _.,
The municipal building inspection office and also to o;� `�' '� �:�;i F�;1
� DILHR, Safety and Buildings, P.O. Box 7969, Madison, WI 53707 � �,. r' '` 1 t;� �,
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Personally identifiable information may be used for other purposes. `., ,_ �
1. PROJECTINFORMATION: (UsetheDlLHRormunicipalprojectlabel,ortypeorprinttheinformation)'�'�`%�
Owner Information Pro�ect Informatio'n ; .:; :�- , :...
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;ui ing Location num er & street
] City ❑ Village ❑ Town of
�ounty o
roperty I enti ication Num er
uilding Project #
Projed #
2. PURPOSE OF THIS STATEMENT: �Check Box A B, or C to indicate purpose and complete any other applicable
oxes and in�ormation. Attach additional pages if necessary.)
❑ Building and HVAC ❑ Building Only �[� HVACOnIy
❑ Partial Completion
Description of Portion Completed
A) � Statement of Substantial Compliance
To the best of my knowledge, belief, and based on onsite observation, construdion of the following building and/or HVAC items applicable to
this projed have been completed in substantial compliance with the approved plans and specifications.
❑ BUILDING ITEMS
'[� HVAC ITEMS
1. Structural system including submittal and erection of all 1. HVAC system including final test
buildi�3-comp�nents (trusses; precast;:metal building, �tc.) QLHR 64.53)
2. Fire protection systems (sprinklers, alarms, smoke detectors)
designed and installed by appropriately registered professionals
3. Exits including exit and directional lights 2. All conditions of HVAC plan approval
�. Shait and stairway enclosures �- and applicable variances
5. Fire-resistive construction, enclosure of hazards, fire walls,
labeled doors, class of construction
6. Sanitation system-(toilets;�sinks;�drinking facilities) � , � � �
7. ILHR barrier free requirements
8. All conditions of building plan approval and applicable variances .
The following items are not in compliance and must be addressed: �
B) ❑ Statement of Noncompliance
Due to the following listed violations, this project is not ready for occupancy:
C) ❑ Supervising Professional Withdrawn From Project Date Withdrawn
(Use A or B above to indicate projed status as of this date.)
D) ❑ Abandoned
3. SIGNATURES:
�- �
Building Supervising Professional �Date
SBD-9720 (R. 01/'94)