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Home My WebLink AboutState Deferal of Inspection Formreet COLORADO Depadment of local Affairs Division of Housing v,J<;eil0t dlSarl SG,at ev< 3t{ NEw Cw'le, CO 6lt'97 "AC" (Alternative Construction) Form Please read below before signing form. Please see the attached Document at bottom of form for specific plan and factory information. To: The Local Authority Having Jurisdiction (LAHJ) or other DOH approved third party inspection agency. By signing this form, you confirm that you have received and reviewed this form, and acknowledge that the above identified components are required to complete the construction of this modular structure onsite within you r jurisdiction. Building Official Responsibility Please check the box labeled "Accept" and initial to confirm that you will take responsibility for inspections of the "AC" lnspection ltems on behalf of the DOH. You also acknowledge that it will be done to the DOH approved plans. lf you would like to defer inspection of the "AC" lnspection ltems back to the DOH, please check the box labeled "Defer lnspection". *ATTENTION* An "AC" lnspection ltem is a component that was not provided at an off-site location to complete the compliance of the factory-built structure. This component is shipped to the site location for the completion of that structure. Components identifled as "AC" lnspection ltems relate to the durability, quality, and safety of the structure, to include the Structural, Mechanical, Electrical, Plumbing, Eneregy, Fire protection, and Life Safety components. A Local lnspection ltem is any site construction that the LAHJ is capable of inspecting from start to finish of the construction process. Local lnspection ltems are open construction and all components are easily visible before they are concealed within cavities of the wall, floor, and ceiling construction. lf the LAHJ defers the "AC" linspection ltems, it is still responsible for reviewing and inspecting the items listed as Local lnspection ltems. Those items are not considered "AC" lnspection ltems and therefore do not fall under the purview of the DOH state regulatory program covering the construction of all factory-built structures (modular) in Colorado. However, they are important to be accounted for before a Certificate of Occupancy (C/O) should be issued for the structure. Fire Safety Official Responsibility (if applicable) The DOH defers the requirement of any fire protection system for all modular IBC (Section 901.2) and IRC I -TOUAT HOUSING O PPORlUNITY 1313 Sherman St., Rm 320, Denver, C0 80203 | (303) 864-7810 | cdola.cotorado.gov/housing reet coroRADo Department of local Aflairs Division of Housing An automatic fire sprinkler system shall be installed in buildings (lBC) OR one and two family dwellings and townhouses (lRC) as required by the localjurisdiction where the structure or home will be set. Final tests required by this Section shall be approved by a certified inspector. The inspector must be either an employee of the fire department having jurisdiction or another qualified individual with prior approval of the Colorado Division of Fire Prevention & Control. Please confirm if the LAHJ requires a fire protection system for this modular structure. lf so, please indicate if the inspection will be completed by a fire department (identify which one) or whether it will be completed by the Colorado Division of Fire Prevention & Control. Man ufactu rer Responsi bi lity The registered factory is responsible for manufacturing a structure that is compliant with our Administrative Rules (CCR 1302-14).lf items in the factory have not been completed, only to be completed in the field, you are still responsible for ensuring they have been completed for compliance. Please sign below that you have received this letter and acknowledge the items listed are to complete compliance of the structure, and items are to be inspected and passed for compliance in order to meet Rule 1 . 1 3.1 and section 24-32- 331 1(4), Colorado Revised Statutes (C.R.S.). *ATTENTION* A DOH issued insignia (silver for residential or blue for nonresidential) certifying its construction cannot be affixed to the structure untilall "AC" items are completed on site and pass inspection. The same applies to modular structures manufactured by a certified factory, Acknowledge Receipt and Understanding Normal permits and fees for these site work inspections are to be per the localjurisdiction. ltems listed as "Local lnspection ltems" are to meet the local building requirements. State approved plans for Factory-Built Construction may be obtained from the Builder/Manufacturer. A copy of this completed form is included with the DOH approved plans and must be included with the installation instructions and shipped with the unit. lf the completed form has been damaged or lost during shipping, the factory or its representative can obtain a copy from the DOH. Before any inspection is scheduled at the onsite location or lnstallation Authorization (required for modular homes and multi-family structures) is issued by the DOH, this form will be required to be signed and dated by the Building Official, or Approved Third Party Agent, or Fire Safety Official (if applicable), and submitted to the DOH. The DOH approved AC form will be included with the approved spec file, with the DOH Plan Reviewer signature below and their plan approvalstamp on the page(s) with the AC listed items to be completed at the site location. That approved AC form should be submitted to the appropriate parties described in this form and submitted back to the DOH before any inspection is scheduled at the onsite location or lnstallation Authorization (required for modular homes and multi-family structures) is issued. DOH Plan Reviewer Name G Ard IOUAI HOUSING OPPOTTU NITY 1313 Sherman St., Rm 320, Denver, CO 80203 | (303) 864-7810 | cdota.cotorado.gov/housing rest coroRADo Department of Local Affairs DMsion of Housing DOH Plan Reviewer Signature fr Date December 15, Building Department Representitive Printed Building Department Representitive Signaiure Title dt{t6f 6trrto ruC-- 6ffi<,1*t- o"e-E:i-4 X Defer lnspection emat qreq.ardrev@state.co.us Lr$roe Accept Contact email ffit#Grta.6r<lD- 4MFf(7. <o r4. lf applicable Fire Safety OfficialPrinted Name Fire Safety Official Signature Date Contact email: ls a fire protection system required? (check one)Required Not Required lf required, the inspection is to be performed by (check one): Fire Department: (NAME) OR Colorado Division of Fire Prevention & Control Factory Authorized Quality Assura nce Representative Printed Name Jill Kottwitz Factory Authorized Quality Assurance Representative Kottwitz, Jill lf;:lxy"r,i*tv*0Dc che'nd Dc-ner oate 1 2/8122 Contact email j i ll, kottwitz@ch ief i nd.com lf the inspection has been deferred and the factory elects to utilize an Approved Third Party Agency to inspect the "AC" items on behalf of DOH, please sign and date below. Approved Third Party Age nt Printed Name tauAr fiousrNo OPPOTIUNIIY 1313 Sherman St., Rm 320, Denver, CO 80203 | (303) 864-7810 | cdola.colorado.gov/housing reel cotoRADo Depanment of tocal Affairs Division of Housing Approved Third Party Agent Sig nature Contact email Verify I nspection(s) Completed Once you have completed all of your assigned inspections identified in this form and they have passed for compliance, please sign and date below. Building Department Rep resentitive Printed Name Building Department Representitive Date Contact email Or Approved Third Party Agent Printed Name Approved Third Party Agent Signatu Date Contact email:_ Fire Protection Systems (if applicable) Fire Safety OfficialPrinted Name Fire Safety Official Sig nature ate Contact email: Please direct questions to manufactured.plans@state.co.us\ IOUAT HOUSING O PPOTIUNITY 1313 Sherman St., Rm 320, Denver, CO 80203 | (303) 864-7810 | cdola.cotorado.gov/housing reel coroRADo Department of local Affairs Division of Housing The following is based on information provided to the Division of Housing (DOH) and may be modified based on the actual findings of the field inspection. DArE: 11/Zl202Z MANUFA6TURER: BOnnaVilla rD No.: 3276 coNrAcr: Jill Kottwitz / iill.kottwitz@chiefind m PHoNE No.: 402-694-5250 M.DEL No.. PlD6428 2g-Mg4B34 DoH p/A No.: R-0005096AC INSPECTION REQUIREMENTS: Check on site: "AC" lnspeclion 1, DORMERS 2. DORMER WINDOWS 3. LATERAL TRUSS BRACING 4. LOFT ELECTRICAL 5. THERMAL CLOSE OFF OF STAIRWELL TO LOFT 6. GABLE WALLS 7. COLLAR TIES 8. TRUSS TOP CHORD GUSSET 9. MATE LINE PORCH POST - TEMPORARY POST INSTALLED IN FACTORY Local lnspection 1. RECESSED DRYER VENT 2. CRAWLSPACE INSULATION 3. GAS LINE . FURNACE / RANGE 4. SMOKE ALARMS IN LOFT 5. HANDRAIL 6. OUTSIDE SERVICE EMERGENCY DISCONNECT 7, SERVICE SURGE PROTECTION IOUAT HOUSING OPPONIUNIIY 1313 Sherman St., Rm 320, Denver, CO 80203 | (303) 864-7810 | cdola.colorado.gov/housing