Health & Life Safety Manual - Electronic Resource Center

DISTRICT NAME AND NUMBERCOUNTYFACIL ITY NAMEFACILITY LOCATIONAPPLICATION FOR OCCUPANCY PERMIT¨ Permanent¨ Temporary¨ Partial¨ Property is owned by the district.¨ Property not owned by district (Attach Authorizationby Owner)Project # __________________________________¨ New Construction¨ Addition¨ Renovation/RemodelingARCHITECT/ENGINEER’S STATEMENT OF BUILDING COMPLIANCE/PROJECT COMPLETIONI, _____________________________________, hereby certify that, based upon my survey of the abovenamed facility on __________________________, and to the best of my knowledge and belief, the abovementioned project number ______________________ has been completed in full compliance with “The HealthLife/Safety Code for Public Schools,” 23 Illinois Administrative Code 180.This Statement of £ Building Compliance or £ Project Completion is valid as of the day of the survey indicatedabove. Changes to the facility or conditions affecting it after that date may render this statement invalid.Signed this __________ day of _______________________, ______(Seal)Typed Name of Architect/EngineerSignature of Architect/EngineerName of Firm License Number Expiration DateApplication is hereby made for issuance of an Occupancy Permit to occupy the above named facility for theprimary purpose of:_________________________________________________________________________________.The facility was surveyed by ___________________________________on ______________ and wasRegional Superintendent DesigneeDatefound to comply with the requirements specified in the Health/Life Safety Code for Public Schools for such afacility.Date President of the Board of Education Date District SuperintendentForm 36-15 (3/04) (Prescribed by Regional Superintendent for local board use) 180.225 and 180.230 a)1-11