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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 areas 50,000 cubic feet or greater (SPS 361.40(4)). 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. Submit Completed Form: City of Middleton OR [EMAIL REDACTED] Building Inspection 7426 Hubbard Ave Middleton, WI 53562 Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04 1. PROJECT INFORMATION: Please fill in the following with information from your plan approval letter. Tenant Name or Suite Site Location (Number & Street) Building Permit ID 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 HVAC Lighting Object 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 (trusses, precast, metal building, etc.) 10. Exterior lighting & control requirements 11. Interior lighting & control requirements 2. Fire protection systems (sprinklers, alarms, smoke detectors) designed, installed, and tested (including forward flow on back flow devices) by appropriately registered professionals 12. All conditions of lighting plan approval and applicable variances 3. Shaft and stairway enclosure 4. Exits including exit and directional lights 5. Fire-resistive construction, enclosure of hazards, fire walls, labeled doors, class of construction, fire stopped penetrations HVAC ITEMS 6. Sanitation system (toilets, sinks, drinking facilities) 1. HVAC system including final test 7. Barrier-free including Comm 18 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: Name Phone Signature