Form Sbd-9720 - Buildings, Hvac, Compliance Statement printable pdf download

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 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.

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

 Industry Services Division, the office of the original plan review.

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 Industry Services.

Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 (1)(m)].

PROJECT INFORMATION:

Please fill in the following with information from your plan approval letter.

Transaction ID Number ___________________ Project Name_________________________________________

Site Number _______________________________

Site location (number & street) _______________________________________________

 City

 Village

 Town of ______________________ County of __________________________

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:  Building Object ID # _______________  HVAC Object ID # _______________

 Partial Completion __________________________________________________________________________

Description of Portion Completed

A)  Statement of Substantial Compliance

To the best of my knowledge, belief, and based on onsite 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.

 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,

12. All conditions of lighting plan approval

installed, and tested (including forward flow on back flow devices) by

and applicable variances

appropriately registered professionals

3. Shaft and stairway enclosure

4. Exits including exit and directional lights

 HVAC ITEMS

5. Fire-resistive construction, enclosure of hazards, fire walls, labeled doors, class

of construction, fire stopped penetrations

6. Sanitation system (toilets, sinks, drinking facilities)

1. HVAC system including final test

7. Barrier-free including SPS 318 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: _________________________________________

__________________________________________________________________________________________________

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. SUPERVISING PROFESSIONAL SIGNATURE FOR:

 Building

 HVAC

________________________________________________________ Date ____________________________

Name (please print or type)

____________________________________

Phone number _________________ Customer ID # ____________________ Signature

SBD-9720 (R.9/15)

Form Sbd-9720 - Buildings, Hvac, Compliance Statement

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