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.
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
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-
14. Estimated Cost - Include the total cost of construction, including materials and market rate labor, but not the cost of land or
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
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.