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Home My WebLink AboutDefer Inspections FormC 0 L 0 R A D 0 Department of Local Affairs Division of Housing JULY 2023 Please confirm if the LAHJ requires a fire protection system and/or wild fire mititgation for this modular structure. If 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 Et Control. Manufacturer Responsibility The registered manufacturer is responsible for manufacturing a structure that is compliant with our Administrative Rues (CCR 1302-14). If 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 1.13.1 and section 24-32-3311(4), Colorado Revised Statutes (C.R.S.). *ATTENTION* A DOH issued insignia (silver for residential or blue for nonresidential or pink for tiny homes or black for multi -family) certifying its construction cannot be affixed to the structure until all "OC" items are completed on site and pass inspection. The same applies to modular structures manufactured by a certified manufacturer. Acknowledge Receipt and Understanding inspections are to be per the local jurisdiction. Normal permits and fees for these site work p 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. If the completed form has been damaged or lost during shipping, the manufacturer or its representative can obtain a copy from the DOH. Before any inspection is scheduled at the on -site location or Installation 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 OC form will be included with the approved spec file, with the DOH Plan Reviewer signature below and their plan approval stamp on the page(s) with the OC listed items to be completed at the site location. That approved OC 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 Installation Authorization (required for modular homes and multi -family structures) is issued. DOH Plan Reviewer Name James Trout DOH Plan Reviewer Signature_ - Date Approved 1 013n/25 Contact email: Governor Jared S. Polis I Rick M. Garcia, Executive Director I Alison George, Division Director 1313 Sherman St., Room 320, Denver, CO 80203 P 303.864.7810 F 303.864.7857 TDD/TrY 303.864.7758 www.dola.cotorado.gov . Strengthening Colorado Communities EQUAL NOUSN6 OPPORTUNITY r j . COLORADO ` Department of Local Affairs Division of Housing J U LY 2023 Building Department Representitive Printed Name Building Department Representitive Signature Title 1�h 25 '4587 Date !Z -15 -7-5 ElAccept Defer Inspection Contact email: / 10 0DV If applicable: Fire Safety Official Printed Name__ Fire Safety Official Signature Contact email: Is a fire protection system required? (check one) Required If required, the inspection is to be performed by (check one): Fire Department: (NAME)_ OR Colorado Division of Fire Prevention Et Control Manufacturer's Authorized Quality Assurance Representative Printed Name_ Brandi Hansen Date /v74 (�NLotRequDiredld��r SdRGl�� 5 7 ra "IIi� Manufacturer's Authorized Quality Assurance Representative Signature_ B1WI TIRKSeK Date 9 . 9 . 2 5 Contact email: brandi@smartpads.co If the inspection has been deferred and the manufacturer elects to utilize an Approved Third Party Agency to inspect the "OC" items on behalf of DOH, please sign and date below. Approved Third Party Agent Printed Name - Approved Third Party Agent Signature Contact email:_ Date Governor Jared S. Polis I Rick M. Garcia, Executive Director I Alison George, Division Director r& 1313 Sherman St., Room 320, Denver, CO 80203 P 303.864.7810 F 303.864.7857 TDD/TTY 303.864.7758 www.dola.colorado.gov Strengthening Colorado Communities EQUAL HOUSMG OPPORTUNITY " " cvLaRAaa Y Department of Local Affairs Division of Housing J U LY 2023 Verify Inspection(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 Representitive Printed Name Building Department Representitive Signature_ Date Contact email:_ Or Approved Third Party Agent Printed Nan Approved Third Party Agent Signature, Contact email_ Fire Protection Systems (if applicable) Fire Safety Official Printed Name Fire Safety Official Signature Contact email: _late Please direct questions to manufactured.Ptans@state.co.us Governor Jared S. Polis I Rick M. Garcia, Executive Director I Alison George, Division Director 1313 Sherman St., Room 320, Denver, CO 80203 P 303.864.7810 F 303.864.7857 TDD/TTY 303.864.7758 www.dola.cotorado.gov f~ ?Y ■1� Strengthening Colorado Communities EQUAL HOUSING OPPORTUNITY ;�- COLORADO r'V Department of Local Affairs Division of Housing JULY 2023 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. DATE: 9.8.25 MANUFACTURER:SummitMods CONTACT: Kathryn Stassen nnnnc:l mn - Custom Leadville INSPECTION REQUIREMENTS: Check on site: "OC" Inspection Items Completion of MEP connections per plan Completion of Thermal envelope per plan Final hookup of appliances compliance with solar and EV ready code completion of air barrier checklist Completion of blower door test ID NO.: 5307 PHONE NO.: 970-819-8107 DOH PiA NO.: R-00071250C . Governor Jared S. Polis I Rick M_ Garcia, Executive Director I Alison George, Division Directorafr,. 1313 Sherman St., Room 320, Denver, Co 80203 P 303.864.7810 F 303.864.7857 TDD/TTY 303.864.7758 www.dola.cotorado.gov Strengthening Colorado Communities x' EQUAL HOLISM � 8 i� ► OPPORTUNITY