Free Compliance Statement-F-62495 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62495 (Rev. 12/08)

STATE OF WISCONSIN

COMPLIANCE STATEMENT
· · · Completion and submission of this form is required by COMM 61.50 prior to initial occupancy of a new building or addition and prior to final occupancy of an alteration of an existing building. This form must be completed and available at the time of the final construction inspection. This form is to be completed by the supervising professional responsible for (1) building, (2) HVAC, (3) lighting, (4) fire protection, (5) component work separate from building, or (6) partial completion. A project may require multiple supervising professionals to complete and submit this form for each of their particular areas of responsibility. The supervising architect, engineer, or designer shall file this form with the Department of Health Services (DHS) certifying that construction of the portion to be occupied has been performed in substantial compliance with the approved plans and specifications. If you have questions about completion or use of this form, call (608) 264-7748, e-mail [email protected] , or contact your DQA Engineer: Hospitals
Telephone FAX

· ·

Adult Family Homes / CBRFs / Nursing Homes
Telephone FAX

Tom Ankeny Richard Batchelder Bill Lauzon Ganesh Shrestha Lynn Wallace

608-264-7743 414-220-5306 414-227-4149 414-227-2004 608-264-9830

608-264-9847 414-227-4139 414-227-4139 414-227-4139 608-264-9847

Romaine Anderson David Beyer Michael Roberts Keith Weitner

715-836-6751 608-516-2449 715-365-2814 414-227-2003

715-836-2535 608-266-8975 715-365-2815 414-227-4139

I. OWNER / ENTITY INFORMATION
Name ­ Owner / Entity DHS Reference Number

Name ­ Company (if different than above) Street Address City State Zip Code

II. PROJECT INFORMATION
Name - Tenant (if any) Building Occupancy Chapter(s) and Use

Location - Street Address

City

Zip Code

County

Project Description (Briefly describe scope of project.)

III. PURPOSE OF STATEMENT
Check the appropriate box and provide any other applicable information to indicate compliance with the approved plans and specifications. Attach additional pages if necessary. Building HVAC Lighting Fire Protection: Fire Alarm System Sprinkler Component Work Separate from Building

Partial Completion (Explain.)

IV. STATEMENT OF SUBSTANTIAL COMPLIANCE To the best of my knowledge and belief and based on onsite observation, this project has been completed in substantial compliance with the approved plans and specifications. SIGNATURE - Supervising Professional
Name ­ Supervising Professional (Print or type.) Date Signed Registration Number

Name ­ Company

Mailing Address - Street or P.O. Box Telephone Number FAX Number

City E-mail Address

State

Zip Code