Dept of Safety & Professional
Services
Industry Services Division
Wisconsin Uniform Building
Permit Application
Application No.
Wisconsin Stats. 101.63, 101.73
Instructions on back of second ply. The information you provide may be
used by other government agency programs [(Privacy Law, s. 15.04 (1)(m)]
Parcel No.
PERMIT REQUESTED
Constr. HVAC Electric Plumbing Erosion Control Other:
Owner’s Name
Mailing Address
Contractor Name & Type
Lic/Cert#
Exp Date
Mailing Address
Dwelling Contractor (Constr.)
Dwelling Contr. Qualifier (The Dwelling Contr.
Qualifier shall be an owner, CEO, COB or employee of the
Dwelling Contr.)
HVAC
Electrical Contractor
Electrical Master Electrician
Plumbing
PROJECT
LOCATION
Lot area
__________ Sq.ft.
One acre or more
of soil will be
disturbed
Town Village
City of
_____________________
_____ 1/4, _____ 1/4, of Section _____, T _____ N, R ______ E/W
Building Address
County
Subdivision Name
Lot No.
Block No.
Zoning District(s)
Zoning Permit No.
Setbacks:
Front
________ ft.
Rear
________ ft.
Left
________ ft.
Right
________ ft.
1. PROJECT
3. OCCUPANCY
6. ELECTRIC
9. HVAC EQUIP.
12. ENERGY SOURCE
New
Repair
Single Family
Entrance Panel
Furnace
Fuel
Nat
LP
Oil
Elec
Solid
Solar
Alteration
Raze
Two Family
Amps: ________
Radiant Basebd
Gas
Geo
Addition
Move
Garage
Underground
Heat Pump
Space Htg
Other:
Other:
Overhead
Boiler
Water Htg
7.WALLS
Central AC
2. AREA INVOLVED (sq ft)
4. CONST. TYPE
Wood Frame
Fireplace
Unit 1
Unit 2
Total
Site-Built
Steel
Other:
13. HEAT LOSS
Unfin.
Mfd. per WI UDC
ICF
______________________ BTU/HR Total Calculated
Bsmt
Mfd. per US
Timber/Pole
10. SEWER
Envelope and Infiltration Losses (available from "Total
Living
HUD
Other:
Municipal
Building Heating Load" on Rescheck report)
Area
5. STORIES
8. USE
Sanitary Permit#
Garage
1-Story
Seasonal
________________
14. EST. BUILDING COST w/o LAND
Deck/
Porch
2-Story
Permanent
11. WATER
Other:
Other:
Municipal
Totals
Basement
On-Site Well
$ _________________
I understand that I: am subject to all applicable codes, laws, statutes and ordinances, including those described on the reverse side of the last ply of this form; am subject to any
conditions of this permit; understand that the issuance of this permit creates no legal liability, express or implied, on the state or municipality; and certify that all the above
information is accurate. If one acre or more of soil will be disturbed, I understand that this project is subject to ch. NR 151 regarding additional erosion control and stormwater
management and the owner shall sign the statement on the back of the permit if not signing below. I expressly grant the building inspector, or the inspector's authorized agent,
permission to enter the premises for which this permit is sought at all reasonable hours and for any proper purpose to inspect the work which is being done.
I vouch that I am or will be an owner occupant of this dwelling for which I am applying for an erosion control or construction permit without a Dwelling
Contractor Certification and have read the cautionary statement regarding contractor responsibility on the second page of this form.
APPLICANT (Print:) __________________________ Sign:_____________________________
DATE ________________
APPROVAL CONDITIONS
This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this
permit or other penalty. See attached for conditions of approval.
ISSUING
JURISDICTION
Town of County of _______________
Village of State ___________________
City of ________________________________________
State-Contracted Inspection
Agency#:
_______________________
Municipality Number of Dwelling Location
______ ______ ______ ______ ______
FEES:
PERMIT(S) ISSUED
WIS PERMIT SEAL #
PERMIT ISSUED BY:
Plan Review
Inspection
Wis. Permit Seal
Other
Total
$ ______________
$ ______________
$ ______________
$ ______________
$ ______________
Construction
HVAC
Electrical
Plumbing
Erosion Control
__________________
Name ____________________________________
Date ____________ Tel. _____________________
Cert No. __________________________________
Email: ____________________________________
SBD-5823(R08/17) Distribute: Ply 1 Issuing Jurisdiction; Ply 2- Issuer forwards to state w/in 30 days; Ply 3- Inspector; Ply 4- Applicant
INSTRUCTIONS
The owner, builder or agents shall complete the application form down through the Signature of Applicant block and submit it
and building plans and specifications to the enforcing jurisdiction, which is usually your municipality or county. Permit
application data is used for statewide statistical gathering on new one- and two-family dwellings, as well as for local code
administration. Please type or use ink and press firmly with multi-ply form.
PERMIT REQUESTED
Check off type of Permit Requested, such as structural, HVAC, Electrical or Plumbing.
Fill in owner's current Mailing Address and Telephone Number.
If the project will disturb one acre or more of soil, the project is subject to the additional erosion control and stormwater
provisions of ch. NR 151 of the WI Administrative Code. Checking this box will satisfy the related notification
requirements of ch. NR 216.
Fill in Contractor and Contractor Qualifier Information. Per s. 101.654 (1) WI Stats., an individual taking out an erosion
control or construction permit shall enter his or her dwelling contractor certificate number, and name and certificate
number of the dwelling contractor qualifier employed by the contactor, unless they reside or will reside in the dwelling.
Per s. 101.63 (7) Wis. Stats., the master plumber name and license number must be entered before issuing a plumbing
permit.
PROJECT LOCATION
Fill in Building Address (number and street or sufficient information so that the building inspector can locate the site.
Local zoning, land use and flood plain requirements must be satisfied before a building permit can be issued. County
approval may be necessary.
Fill in Zoning District, lot area and required building setbacks.
PROJECT DATA - Fill in all numbered project data blocks (1-14) with the required information. All data blocks must be
filled in, including the following:
2. Area (involved in project):
Basements - include unfinished area only
Living area - include any finished area including finished areas in basements
Two-family dwellings - include separate and total combined areas
3. Occupancy - Check only "Single-Family" or "Two-Family" if that is what is being worked on. In other words, do not
check either of these two blocks if only a new detached garage is being built, even if it serves a one or two family
dwelling. Instead, check "Garage" and number of stalls. If the project is a community based residential facility serving 3
to 8 residents, it is considered a single-family dwelling.
9. HVAC Equipment - Check only the major source of heat, plus central air conditioning if present. Only check "Radiant
Baseboard" if there is no central source of heat.
10. Sewage - Indicate if the dwelling will be served by municipal sewer or privately owned treatment system. If a private
system is used, include the Sanitary Permit number. Note: A building permit cannot be issued for a new dwelling that
utilizes a privately owned wastewater treatment system until a sanitary permit has been issued. This applies to any new or
existing private onsite wastewater treatment system that will be used by the dwelling.
13. Heat Loss Provide heat loss summation data (BTUs/HR) derived from the ResCheck report or the “Heating System
Sizing Summary Calculator” available on the Division’s website: http://dsps.wi.gov/Programs/Industry-Services/Industry-
Services-Programs/One-and-Two-Family-UDC.
14. Estimated Cost - Include the total cost of construction, including materials and market rate labor, but not the cost of land or
landscaping.
SIGNATURE The owner or the contractor’s authorized agent shall sign and date this application form. If you do not possess
the Dwelling Contractor certification, then you will need to check the owner-occupancy statement for any erosion control or
construction permits.
CONDITIONS OF APPROVAL - The authority having jurisdiction uses this section to state any conditions that must be
complied with pursuant to issuing the building permit.
ISSUING JURISDICTION: This must be completed by the authority having jurisdiction.
Check off Jurisdiction Status, such as town, village, city, county or state and fill in Municipality Name
Fill in State Inspection Agency number only if working under state inspection jurisdiction.
Fill in Municipality Number of Dwelling Location
Check off type of Permit Issued, such as construction, HVAC, electrical or plumbing.
Fill in Wisconsin Uniform Permit Seal Number, if project is a new one- or two-family dwelling.
Fill in Name and Inspector Certification Number of person reviewing building plans and date building permit issued.
(Part of Ply 4 for Applicants)
Cautionary Statement to Owners Obtaining Building Permits
101.65(lr) of the Wisconsin Statutes requires municipalities that enforce the Uniform Dwelling Code to
provide an owner who applies for a building permit with a statement advising the owner that:
If the owner hires a contractor to perform work under the building permit and the contractor is not bonded
or insured as required under s. 101.654 (2) (a), the following consequences might occur:
(a) The owner may be held liable for any bodily injury to or death of others or for any damage to
the property of others that arises out of the work performed under the building permit or that is caused by
any negligence by the contractor that occurs in connection with the work performed under the building
permit.
(b) The owner may not be able to collect from the contractor damages for any loss sustained by
the owner because of a violation by the contractor of the one- and two- family dwelling code or an
ordinance enacted under sub. (1) (a), because of any bodily injury to or death of others or damage to the
property of others that arises out of the work performed under the building permit or because of any
bodily injury to or death of others or damage to the property of others that is caused by any negligence by
the contractor that occurs in connection with the work performed under the building permit.
Cautionary Statement to Contractors for Projects Involving Building Built Before 1978
If this project is in a dwelling or child-occupied facility, built before 1978, and disturbs 6 sq. ft. or more
of paint per room, 20 sq. ft. or more of exterior paint, or involves windows, then the requirements of ch.
DHS 163 requiring Lead-Safe Renovation Training and Certification apply. Call (608)261-6876 or go to
the Wisconsin Department of Health Services’ lead homepage for details of how to be in compliance.
Wetlands Notice to Permit Applicants
You are responsible for complying with state and federal laws concerning the construction near or on
wetlands, lakes, and streams. Wetlands that are not associated with open water can be difficult to
identify. Failure to comply may result in removal or modification of construction that violates the law or
other penalties or costs. For more information, visit the Department of Natural Resources wetlands
identification web page or contact a Department of Natural Resources service center.
Additional Responsibilities for Owners of Projects Disturbing One or More Acre of Soil
I understand that this project is subject to ch. NR 151 regarding additional erosion control and stormwater
management standards, and will comply with those standards.
Owner's Signature: _______________________________________ Date:___________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome