Fillable Form 967 New Home Construction (City of Green Bay)

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Form 967 New Home Construction (City of Green Bay)

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City of Green Bay
Department of Community and Economic Development
NEW RESIDENCE PERMIT
PLAN APPROVAL FEES
The fe
es for the following will be paid at the time the permit is dropped off
for review:
Site
Plan Review Fee $50
Building Plan Review Fee $50
Erosion Control Plan Review Fee $25
*Floodplain or Wetland Property (if applicable) $25
Total $125
*Total if Floodplain or Wetland
$150
The fees for the following will be paid at the time the permit is picked up:
• Building Permit
• Electrical Permit
• Heating Permit
• Plumbing Permit
• Sanitary Sewer & Water Permit
• Storm Sewer Permit
• UDC Seal
• Certificate of Occupancy
• Erosion Control Permit
• Curb Cut Permit
100 North Jefferson Street, Room 608, Green Bay, Wisconsin 54301-5026
(p) 920.448.3300 (f) 920.448.3426 greenbaywi.gov
(Rev 5/20)
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
To: Wisconsin Uniform Building Permit Recipient
Application for a Wisconsin Uniform Building Permit shall be on forms obtained from the City of Green
Bay Inspection Division. The Inspection Division has the responsibility of administering and enforcing the
code. No application shall be accepted that does not contain all the information requested on the forms.
Permits will be issued from 3-10 days after submission of complete application and plans.
Procedure for Obtaining Building Permit
Step 1 – Obtain Street Address from Inspection Division, Room 610
Prior to submitting the application forms and plans, the street address shall be assigned. Provide the
Inspection Division with the street name and legal description of the property, which includes the
Subdivision Name, Lot Number, and Parcel Number or Certified Survey Map Number. You may obtain
the street address in person or by emailing the request to inspmail@greenbaywi.gov. A specific address
request will be honored if it falls in an acceptable range.
Step 2 – Submission of Application and Plans
The following forms and plans shall be submitted to the Inspection Division with the assigned street
address identification on all submissions:
Fill out DSPS online building permit application (ACT 211)
2 11x17 size copies of site plan
2 copies of erosion control plan
2 copies of building plans, including wall brace plan and calculations
1 complete copy of the building plan in digital format (PDF file) emailed to siteplangb@greenbaywi.gov.
Application for Internal Plumbing Permit signed by Master Plumber, with water calculations.
Application for External Plumbing Permit (storm, sewer and water connection permit)
Application for Heating Permit and Heat Loss Calculations, both signed by Licensed Heating
Contractor
Application for Electrical Permit signed by Master Electrician
Curb cut permit
Fees associated with the review of the project (site plan, building plan, and erosion control plan)
Step 3 – Review of Submittal and Determination of Fees
The Building Inspector shall review the submittal and notify the applicant immediately if any required
information is missing or incomplete. If the required information is not received within 30 days, the
permit will be denied and the plans returned and stamped “Not Approved.” See the current Fee Schedule
to determine the fees.
Step 4 – Issuance of Building Permits
The Building Inspector shall notify the applicant that the plans have been approved and the amount of the
fees required. The following fees must be paid before the project can begin: Building, Electrical,
Plumbing, Heating, Storm, Sanitary, Water, Erosion Control, UDC Seal, Certificate of Occupancy, and
Curb Cut/Culvert. After all the fees are paid, the following permit information will be released and work
may begin: Permit Fee Receipts, Letter to Wisconsin UDC Permit Recipient, Owner/Agent Copy of UDC
Permit Application, Sewer and Water Installation Permit, Curb Cut/Culvert Permit, Erosion Control,
UDC Permit Card with seal, copy of Conditionally Approved Site Plan, Erosion Control Plan, and Building
Plans.
(Rev 3/19)
ACT 211 - NEW HOME PERMITTING PROCESS
Revision 6/22/17
Wisconsin Uniform Building Permit ELECTRONIC Application Process
DIRECTIONS AND TIPS:
1. Log into DSPS site at:
https://verification.dsps.wi.gov/buildingpermit/application/Directions.aspx
Here is a helpful link to a guide on the State application process and ACT 211:
http://dsps.wi.gov/Documents/Industry%20Services/Forms/UDC/2017%20ACT%20211_excel.pdf
2. Complete the application
a. Be sure to include phone numbers when asked
b. Be sure to include emails when asked
3. Print out the completed application form from the web site
4. Submit the application packet to the City as you currently do
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
To: Wisconsin Uniform Building Permit Recipient
Your building will be reviewed for conformance with applicable Wisconsin Administrative Codes and
City of Green Bay Ordinances. Once the plans have been “Conditionally Approved”, the Uniform
Building permit will be issued. This plan action will be subject to the approval conditions listed on
the permit application. The owner, as defined in Chapter 101.01(2)(e), Wisconsin Statutes, is
responsible for compliance with all code requirements.
Lot Corners Monumented
Section 15.24 of the Green Bay Ordinances requires that all lot corners of the property upon which any
building is to be located shall be or have been monumented by a registered land surveyor. The
monuments shall be marked by wood guard stakes and maintained and kept readily visible until the footings
have been inspected and approved by the Building Inspector.
Posting of Permit
The Wisconsin Uniform Building Permit shall be posted in a conspicuous place at the dwelling site.
Required Inspections
To schedule the required inspections listed below, call (920) 448-3300 between 8:00 a.m. and 4:00 p.m., at
least one business day prior to inspection date needed. Do not leave inspection requests on voicemail.
The street address, associated project number, and type of inspection must be given when requesting an
inspection.
1.
Footing – After placement of forms, shoring, and reinforcement where required and prior to the
placement of footing materials. Lot corners must be monumented to approve inspection.
2.
Foundation Wall – After forms are set and any required shoring or reinforcement is in place.
3.
Drain Tile, Stone, & Tar – Prior to backfilling.
4.
Rough Inspection – When general construction framing is completed and electrical, plumbing,
HVAC, and basement drain tiles have been roughed in.
5.
Insulation – When in place.
6.
Final Inspection – When all phases of the building are substantially completed and the building is
ready for occupancy.
Construction shall not
proceed beyond the point of inspection until the inspection has been
completed and approved by the Inspector!
Certificate of Occupancy
No building or part thereof shall be occupied until a final inspection is made which finds that no code
violations exist that could reasonably be expected to affect the health and safety of the occupant and a
Certificate of Occupancy has been issued by the Principal Planner/Building Inspection Manager.
(Rev 3/17)
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 and will comply with those standards.
Owner's Signature: _______________________________________ Date:___________________
Contractor Credential Requirements
All contractors shall possess an appropriate contractor credential issued by the Wisconsin Division of
Industry Services.
Permit process and follow up:
• SETBACKS: Follow Municipal Code 13-604 Table 6-2 on setback requirements for
homes (Chapter 13 Zoning Code).
• SITE PLAN: Follow Municipal Code 13-1800 (Chapter 13 Zoning Code).
• DRIVEWAY REQUIREMENTS: Follow Municipal Code 13-1700 (Chapter 13
Zoning Code).
• SIDEWALK/APRON CONSTRUCTION: Follow Municipal Code Chapter 9
(Public Works).
• EROSION CONTROL: Follow Municipal Code Chapter 34.
o Protection Methods (Silt Fence, Silt Sock, Inlet Protection, etc.) Follow DNR
regulations.
Note: Municipal Code and all applicable information is available on the
City of Green Bay website at http://greenbaywi.gov/law/ordinances
.
SITE PLAN
Address: _______________________
Parcel No: ______________________
Subdivision: _____________________
Lot No.: _______________________
Name of Sewer & Water
Installation Contractor:
Must Be Licensed, Insured, and Bonded
Lot Size and Dimensions
Building(s) Location
Size
Number of Stories
Use
Setbacks from Property Lines
Driveway Location
Width at Property Line
(12’ or 10’ Max. Per Garage Stall)
Setback from Property Line
Curb Cut (Width Plus 5’)
Culvert Length
(Width plus 10’)
Utility Easement
Flood Plain
Wetland or Waterway
Property Line Corner Stake
Front
Setback
Sidewalk
Curb
Street
Two-Family
NATURE OF WORK (check all that apply):
Swimming Pool
Alteration
Remodeling
Repairs
Sign
Addition
Detached Garage
Hot tub/spa
Other ____________
JOB DESCRIPTION:
(REQUIRED)
_______________________________________________
Signature (Master Electrician Responsible For Work)
(REQUIRED)
___________________
Date
INSPECTOR STATEMENT: I hereby certify the work completed as of date signed complies with applicable codes.
____________________
Date
_________________________________________________
Inspector Signature
This section for City use only
Project #:
Permit Code:
Permit Fee:
Parcel #:
Receipt #:
Date:
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
LICENSED
CONTRACTOR
ELECTRICAL PERMIT
Check box for Online Payment
The information below must be provided for notification of project number and permit fee. This information is
required to make payment on-line.
Educational
Other
Multi-Family
Number of Units
Manufacturing
Phone _________________
Fax ________________
________
To schedule an inspection, submit an online Inspection Request or call (920) 448-3300 at least one
business day in advance. Final inspections are required for all projects.
CONTRACTOR STATEMENT: I hereby certify that the above wiring upon completion will be in compliance with
the applicable federal, state, and local electrical codes and utility service rules.
“ENERGIZING THE DESCRIBED WIRING WILL IN NO WAY CREATE A HAZARD”
State of WI Electrical Contractor Certification # _____________ and WI Master Certification # _______________
Email ____________________________
(Rev 6/20)
www.greenbaywi.gov
All fields must be completed before permit will be processed.
Project Address: __________________________________________________
Owner's Name: __________________________________________________
Owner's Email: Phone #:
Electrical Contractor: ______________________________________________
Contractor's Address: ______________________________________________
Contractor’s Email: ________________________________________________
Contractor’s Phone #: ___________________ Cell #: _____________________
Value of work: ___________________________________________________
Single-Family
Commercial
OCCUPANCY (check appropriate box):
click to sign
signature
click to edit
click to sign
signature
click to edit
www.greenbaywi.gov
FURNACE: Gas ___________ Electric __________ Oil __________ Forced Air __________
AIR CONDITIONER: Forced Air __________ Central Air __________
BOILER: Steam _______ Hot Water ________ Res ________ Industrial ________ Commercial _______
SPACE HEATER: Type __________ Unit __________
Class __________
Contractor’s Signature: ___________________________________ Credential # _____________________
Check box for Online Payment
The information below must be provided for notification of project number and permit fee. This information is
required to make payment on-line.
Phone ___________________ Fax _____________________
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
LICENSED
CONTRACTOR
HEATING PERMIT
This section for City use only
Project #:
Permit Code:
Permit Fee:
Parcel #:
Receipt #:
Date:
To schedule an inspection, submit an online Inspection Request or call (920) 448-3300 at least one
business day in advance. Final inspections are required for all projects.
Email ________________________
(Rev 6/20)
All fields must be completed before permit will be processed.
Project Address:
Owner's Name:
Phone #:Owner's Email:
Heating Contractor:
Contractor's Address:
Contractor’s Email:
Contractor's Phone #:
Unit Price: Value of Work:
I hereby make application for a permit for the following described heating work at the above location.
Check all that apply:
click to sign
signature
click to edit
www.greenbay.wi.gov
LICENSED CONTRACTOR
PLUMBING PERMIT
(INTERNAL)
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
All fields must be completed before permit will be processed.
Project Address:
Owner's Name:
Phone #: Owner's Email:
Plumbing/Utility Contractor:
Contractor’s Address:
Contractor's Email:
Contractor's Phone #:
Value of Work:
I hereby make application for a permit for the following described sewer/plumbing work at the above location.
General Interior Plumbing
Total Number of Fixtures
Total Number of Appliances
Total Number of Appurtenances
Total Count
Description of Work:
To schedule an inspection, submit an online Inspection Request or call (920) 448-3300 at least one business
day in advance. Final inspections are required for all projects.
Contractor's Signature:
Master Plumber Credential #
Check box for Online Payment
The information below must be provided for notification of project number and permit fee. This information is required to make
payment online.
Phone
Fax
Email
Excerpt from City of Green Bay Plumbing Code:
Section 16.06 Permit must be procured before starting work: If any work regulated by the Plumbing Ordinance for which a permit is required
is commenced without a permit first having been obtained thereof, double the permit fee herein prescribed shall be paid when a permit finally
is obtained. Payment of any fee mentioned in this Section, however, shall in no way relieve any person of the penalties that may be imposed for
violation of the Plumbing Ordinance.
(Rev 6/2020)
This section for City use only
Project #:
Permit Code:
Permit Fee:
Parcel #:
Receipt #:
Date:
www.greenbay.wi.gov
STORM, SANITARY
AND WATER
CONNECTION PERMIT
(EXTERNAL)
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
All fields must be completed before permit will be processed.
Project Address:
Owner's Name:
Owner's Email: Phone #:
Plumbing/Utility Contractor:
Contractor’s Address:
Contractor's Email:
Contractor's Phone #: Value of Work:
Bonded/Insured with City of Green Bay:
Yes
No
(For right-of-way impact)
I hereby make application for a permit for the following described sewer/plumbing work at the above location.
External Plumbing/Sewer
Water Service Connection
Sewer Cap
Sanitary Sewer Connection
Sanitary/Storm/Water Repair
Storm Sewer Connection
Description of Work:
To schedule an inspection, submit an online Inspection Request or call (920) 448-3300 at least one business
day in advance. Final inspections are required for all projects.
Contractor's Signature:
Credential #
Check box for Online Payment
The information below must be provided for notification of project number and permit fee. This information is required to make
payment online.
Phone
Fax
Email
Excerpt from City of Green Bay Plumbing Code:
Section 16.06 Permit must be procured before starting work: If any work regulated by the Plumbing Ordinance for which a permit is required
is commenced without a permit first having been obtained thereof, double the permit fee herein prescribed shall be paid when a permit finally
is obtained. Payment of any fee mentioned in this Section, however, shall in no way relieve any person of the penalties that may be imposed for
violation of the Plumbing Ordinance.
(Rev 6/2020)
This section for City use only
Sewer Request Filed:
Sewer Verified:
Project #:
Permit Code:
Permit Fee:
Assessment Fee:
Parcel #:
Receipt #:
Date:
Water Calc. Worksheet
Name of Project
INFORMATION REQUIRED TO SIZE WATER SERVICE AND WATER DISTRIBUTION:
1- Demand of building in water supply fixture units (WSFU);
1.a.
Demand of building in WSFU converted to Gallons Per Minute:
(GPM)
(Table SPS 382.40-3)
2- Elevation difference from main or external pressure tank to building control valve; (feet)
3- Size of water meter (when required) 5/8" 3/4" 1" other
4- Developed length from main or external pressure tank to building control valve; (feet)
5- Low pressure at main in street or external pressure tank. (psi)
CALCULATE WATER SERVICE PRESSURE LOSS
(unnecessary for internal pressure tanks)
6- Low pressure at main in street or external pressure tank. (value of # 5 above)
7-
Determine pressure loss due to friction in
inch diameter water service.
Water service piping material is
Pressure loss per 100 ft. = X (decimal equivalent of
service length, i.e. 65 ft = 0.65) Subtract value of "7"
Subtotal
8- Determine pressure loss or gain due to elevation, Subtract value of "8"
(multiply the value of # 2 above by .434)
9- Available pressure after the bldg. control valve. Subtotal
CALCULATE THE PRESSURE AVAILABLE FOR UNIFORM LOSS (VALUE OF "A")
B. Available pressure after the bldg. control valve. (from "9" above) Value of "B"
C. Pressure loss of water meter (when meter is required) Subtract value of "C"
Subtotal
D. Pressure at controlling fixture*.
(Controlling fixture is: ). Subtract value of "D"
(*Contolling fixture is the fixture with the most demanding pressure to
operate properly which includes the following when determining
Subtotal
fixture performance; loss due to instantaneous water heaters, water
treatment devices, and backflow preventers which serve the controlling fixture.)
E. Difference in elevation between building control valve
and the controlling fixture in fee
t
;
X .434 psi/ft. Subtract value of "E"
Subtotal
SBD -6479 (R01/12) ( page 1 of 2 )
(WSFU)
Water Calc Worksheet
F. Pressure loss due to water treatment devices and backflow preventers
which serve the controlling fixture
. (Water softeners, filters, etc.)
(Pressure loss due to;
).
F1. WSFU Downstream of Water Treatment Device;
F2. Convert wsfu to GPM using Table 382.40-3:
o
r
F3. Convert wsfu to GPM using Table 382.40-3e*
(For individual dwellings only)
F4. Refer to manuf. graph to obtain pressure loss:
( If no water treatment device enter "0")
Subtract value of F4
Subtotal
G. Pressure loss through tankless water heaters, combination boiler / hot water
heaters, heat exchangers which serve the controlling fixture
;
Hot water WSFU's; convert to; GPM = (Table 382.40-3)
Refer to manufacturer's pressure loss graph to determine loss at the required GPM;
pressure loss. Subtract value of "G"
Subtotal
H.
Developed length from building control valve to controlling
fixture in fee
t
X 1.5 Divide by value "H"
Subtotal
Multiply by: 100
A. Pressure available for uniform loss "A"
=
Water distribution piping is:
*Note: The "A" value obtained by using Table 382.40-3e can only be used for an individual dwelling
when sizing the water treatment device (water softeners, etc) and no hose bibbs,
hydrants, or high flow fixtures are being served by the water treatment device.
Note: High flow fixtures are defined as fixtures that exceed a flow rate of 4 gpm @ 80 psi,
and water velocity not exceeding 8 ft. per second.
SBD -6479 (R01/12) (page 2 of 2)
Name of Project
(Rev 01/17)
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
Small Site General Instructions: Submit this application and erosion control plan demonstrating compliance with Ch. 34,
Green Bay Municipal Ordinance and/or Ch. SPS 321.125, Uniform Dwelling Code, for sites covering less than one acre and/or one-
or two-family residential construction prior to commencing land-disturbing construction or land-development activity to Room 610.
Large Site General Instructions: Submit application and erosion control plan demonstrating reasonable compliance with Ch. 34, Green
Bay Municipal Ordinance, for sites one acre or greater in size prior to commencing land-disturbing construction or land-development
activity to Room 610.
Excavation within Public Rights-Of-Way General Instructions: Submit this application and erosion control
plan demonstrating compliance with Ch. 34, Green Bay Municipal Ordinance for land disturbances covered within section 34.04(1)
(a) 1. 4,000 SF; 4. 100 LF of drainage conveyance impacts; 6. 300 LF of underground utility work; and/or 7. 100 CY or
greater of excavation volume prior to commencing land-disturbing construction or land-development activity to Room 300.
Address/Street of land-disturbing activity:
Parcel #:
Zoning District: Project #:
Site #
APPLICANT
Property Owner
General Contractor
EROSION CONTROL CONTRACTOR
Name Name
Company Company
Address Address
City, State, Zip City, State, Zip
Phone Phone
Email Email
Description of Activity:
Start
End ______________
Erosion Control Plan: (provide 3 copies) *Must demonstrate compliance with Ch. 34, Green Bay Municipal Ordinance and/or Ch. SPS 321.125
UDC, including but not limited to all of the following:
1. Application
2. Property legal description
3. Existing site map / plan
4. Final site map / plan
5. Site construction plan
6. Soil loss prediction tool / spreadsheet
7. Erosion & Sediment Control Plan Statement (Narrative description of who, what,
when, where, how things will be completed on the proposed site(s)).
Applicant Signature: ______________________________________________________________________ Date: ________________________
Following sections to be completed by the City of Green Bay
Plan Approval: Permit is void unless signed by the Erosion Control Specialist.
Erosion Control Plan reviewed and approved by Erosion Control Specialist:___________________________________ Date:____________________
Permit Issuance:
1. Duration – This erosion control permit shall remain valid for a period of 180 days or for the length of the building permit, whichever is longer. The
Erosion Control Specialist or designated representative may extend the period one or more times for up to an additional 180 days, and may require
additional erosion control measures as a condition of the extension if necessary to meet the requirements of this ordinance.
Permit Expiration Date: __________________________________
2. Surety Bond - As a condition of approval and issuance of the permit, the Public Works Director may require the applicant to deposit a surety bond or
irrevocable letter of credit to guarantee a good faith execution of the erosion control plan.
Surety Bond Amount $ __________________________________ Date Filed: _______________________________________
3. Conditions of Approval - This permit approval requires the applicant to:
a. Notify the Erosion Control Specialist / designated representative at least 48 hours before commencing any land-disturbing construction or land-
development.
b. Notify the Erosion Control Specialist / designated representative of completion of any erosion control measures within seven days after their
installation.
c. Obtain permission in writing from the Erosion Control Specialist / designated representative prior to modifying the erosion control plan.
d. Install all erosion control measures as identified in approved erosion control plan.
e. Maintain all road drainage systems, storm water drainage systems, control measures, and other facilities identified in erosion control plan.
f. Repair any siltation or erosion damage to adjoining surfaces and roadways resulting from land-developing construction or land-disturbing activities.
g. Inspect the construction erosion control measures after each rain of 0.5" or more and at least once each week and make needed repairs.
h. Allow the Erosion Control Specialist / designated representative to enter the site for the purpose of inspecting compliance with the erosion
control plan or for performing any work necessary to bring the site into compliance with the erosion control plan.
i. Keep a copy of the approved erosion control plan on the site.
j. Submit weekly inspection reports to the Erosion Control Specialist via e-mail at erosioncontrol@greenbaywi.gov
Failure to comply with any of these conditions may subject the permittee to corrective action, fines, and/or revocation of the permit at
permittees sole expense.
Permit Issued By: __________________________________________ Date:___________________________________
EROSION CONTROL
PERMIT APPLICATION
www.greenbaywi.gov
Raze Site Fill Site Excavation Site
Construction Site
Acres
Same as Applicant
EROSION CONTROL
PLAN SUBMITTAL
APPLICATION
Department of Community
and Economic Development
100 N. Jefferson Street, Rm 608
Green Bay, WI 54301-5026
(920) 448-3300 - phone
(920) 448-3426 - fax
inspmail@greenbaywi.gov
Project Address:
Project Name:
Parcel #:
Project#: Site#:
This form must be completely filled out by the applicant prior to submitting the application. All required information
must be submitted with the application or it will be deemed incomplete and delay the permitting process. Applicants
should initial next to each required field to confirm that it has been provided with the application.
Erosion Control Plan Requirements and Erosion Control Narrative / Statement
Owner Information (Application Form)
Name
Address
Telephone number
E-mail address
Erosion Control Contractor (Application Form)
Name
Address
Telephone number
E-mail address
Site Plan (Existing Site Conditions)
A legal description of the property proposed to be developed
Existing site conditions on a scale of at least 1" equals 100'
Identify site boundaries and adjacent lands which accurately identify site location
Identify lakes, streams, wetlands, channels, ditches, and other water courses on the site and adjacent lands
Identify the location of the 100-year floodplain/flood fringe and floodway
Identify the predominant soil types
Identify the location and general identification of the vegetative cover
Identify the location and dimensions of storm water drainage systems and natural drainage patterns on and
immediately adjacent to the site
Identify the locations and dimensions of utilities, structures, roads, highways, and paving
Identify the site topography at a contour interval not to exceed 2'
Site Construction Plan (Proposed Site Conditions)
Identify the location and dimensions of all proposed land-disturbing construction/activities
Identify the locations and dimensions of all temporary soil or dirt stockpiles
What are the proposed best management practices (BMPs) with installation details
Identify the locations and dimensions of all construction site erosion control measures necessary to meet the
requirements of this ordinance
Schedule of anticipated starting and completion date of each land-disturbing construction or land-developing
activity, including the installation of construction site erosion control measures needed to meet the requirements
of this ordinance
Provisions for maintenance of the construction site erosion control measures during construction
Submittal of all soil loss prediction tool results and iterations
Erosion and Sediment Control Statement/ Narrative
Erosion and sediment control plan statement shall briefly describe the site, the development schedule, and the
BMPs that will be used to meet the requirements of the ordinance
What are the performance standards applicable to the site
Application
Soil Loss Equation Erosion and Sediment Control Narrative Site Plan
Site Construction Plan
Applicant hereby certifies that the information contained herein is complete and accurate to the best of
applicant’s knowledge.
Signed: Date:
(Rev 01/17)
www.greenbaywi.gov
EROSION
CONTROL PLAN
LEGEND
-··-··-··-··-··-··- Property Line
Existing Drainage
TD Temporary Diversion
Finished Drainage
- - - Limits of Grading
     Silt Fence
     Straw Bales
Gravel
Vegetation Specification
Area #1
Tree Preservation
Stockpiled Soil
Stockpiled Soil w/cover
Rip Rap
Sod Channel
Property Location:
Property Owner:
Contractor:
Anticipated Starting Date:
Anticipated Completion Date:
Prepared By: Date:
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Self- Inspections
Promulgated under Chapter 34.10 (5)(h) of the City of Green Bay Construction Site Erosion
Control Ordinance, you are required to conduct construction site inspections at least once per
week and within 24 hours after a precipitation event of 0.5 inches or greater. Repair or replace
erosion and sediment control BMPs as necessary within 24 hours of an inspection or
notification that repair or replacement is needed. Maintain, at the construction site, weekly
written reports of all inspections. Weekly inspection reports shall include all of the following:
1. Date, time and location of the construction site inspection.
2. Name of individual who performed the inspection.
3. An assessment of the condition of the erosion and sediment controls.
4. A description of any erosion and sediment control BMP implementation and
maintenance performed.
5. A description of the present phase of land disturbing construction activity ant the
construction site.
Submit a copy of the weekly inspection report electronically to the Administering Authority.
Under this ordinance, the inspection reports will be submitted to the Department of Public
Works via the following e-mail address: ErosionControl@greenbaywi.gov. See attached blank
inspection form and photo log.
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1
The Universal Soil Loss Equation (USLE) model and the Construction Site Soil Loss and Sediment Discharge Guidance are available at: http://dnr.wi.gov/topic/stormwater/standards/const_standards.html
2
If the project is not on schedule then the soil loss summary for the project should be reviewed and schedule, plan or practices modified accordingly.
State of Wisconsin
Department of Natural Resources (DNR)
PO Box 7921, Madison WI 53707-7921
dnr.wi.gov
CONSTRUCTION SITE INSPECTION REPORT
Form 3400-187 (R 11/16) Page 1 of 2
Notice: This form was developed in accordance with s. NR 216.48 Wis. Adm. Code for WPDES permittees’ convenience; however, use of this specific form is voluntary. Multiple copies of this form
may be made to compile the inspection report. Inspections of the construction site and implemented erosion and sediment control best management practices (BMPs) must be performed weekly
and within 24 hours after a rainfall event 0.5 inches or greater.
Construction Site Name and Location (Project, Municipality, and County):
Site/Facility ID No. (FIN):
Onsite Contact/Contractor:
Onsite Phone/Cell:
Note: Inspection reports, along with erosion control and storm water management plans, are required to be maintained on site in accordance with s. NR 216.48 (4)
and made available upon request. PLEASE PRINT LEGIBLY.
Date of inspection:
Time of inspection:
Start:
am
pm
End:
am
pm
Type of inspection:
Weekly Precipitation Event Other (specify)
Weather/Site Conditions:
Dry Frozen or snow covered
Temp. °F
Antecedent
Variable Frozen (Thaw predicted in next week)
Soil Moisture
Wet Melting Snow/slush
Last Rainfall Depth:
inches
Last Rainfall Date:
Describe current phase of construction:
Scheduled Final Stabilization Date for Universal Soil Loss Equation (USLE)
1
:
Project
on Schedule
2
?
Yes
No
Name(s) of individual(s) performing inspection:
Inspector Phone/Cell:
I certify that the information contained on this form is an accurate assessment of site conditions at the time of inspection:
Inspector Signature
Date:
Inspection Questions:
Yes
No (Identify Actions Required):
Location/Comments:
Actions Completed
by Date & Initials
1.
Is the erosion control plan accessible to operators?
Provide onsite copy
2.
Is the permit certificate posted where visible?
Post certificate
3.
Is the current phase of construction on sequence with
the site-specific erosion and sediment control plan,
including installation/stabilizati
on of ponds and
ditches?
Add sediment control
Install missing ditch/pipe/pond
Stabilize bare soil
4.
Are all erosion and sediment control BMPs shown on
plan properly installed and in functional condition?
Repair
Modify
Install/Replace
5.
Is inlet protection properly installed and functioning in
all inlets likely to receive runoff from the site?
Clean
Replace
Install
6. Is the air free of fugitive dust resulting from
construction activity and bare soil exposure?
Apply water
Apply dust control product
3 If sediment discharge enters a wetland or waterbody, the permittee should consult with DNR staff to determine if sediment cleanup and/or additional control measures are required.
4
The permittee shall notify the DNR immediately via the spills hotline at (800)943-0003 of any release or spill of a hazardous substance to the environment in accordance with s. 292.11, Wis. Stats., and ch. NR 706, Wis. Adm. Code.
State of Wisconsin
Department of Natural Resources
CONSTRUCTION SITE INSPECTION REPORT
dnr.wi.gov
Form 3400-187 (R 11/16) Page 2 of 2
Inspection Questions:
Yes
No (Identify Actions Required):
Location/Comments:
Actions Completed
by Date & Initials
7.
Is the public right of way curb line free of tracked soil
Install tracking pad
and accumulation?
Widen/lengthen pad
Amend stone/Add geotextile
Install wheel washing station
Close entrance/exit
Limit traffic across disturbed areas
Sweep road and curb line
8.
Are wetlands, lakes, streams, ditches, or storm sewers
Repair/Replace erosion control
downstream of the site free of sedimentation and
Add sediment controls
turbid water leaving the site?
3
Modify operations
Contact DNR to verify extent of cleanup
required
9.
Is dewatering and/or vehicle and equipment washing
being done in a manner that prevents erosion and
sediment discharge?
Install treatment train
Install energy dissipation
Modify discharge location
Modify intake to reduce sediment
10.
Are soil stockpiles existing for more than 7 days
covered and stabilized?
Seed
Install mat/mulch/polymer
Cover with tarp/plastic sheeting
11.
Are downstream channels and other downhill areas
protected from scour and erosion?
Install energy dissipation at outfall
Install ditch checks
Install slope interruption
Install onsite detention
12.
Are good housekeeping practices or treatment controls
in place to prevent the discharge of chemicals,
cement, trash, and other materials into wetlands,
waterways, storm sewers, ditches, or drainage-ways?
4
Properly dispose of trash
Provide concrete washout station
Contact DNR to verify extent of cleanup
required
13.
Is the plan reflective of current site operations and
does it address all erosion and sediment control
issues identified during the ins
pection?
Revise sequence
Revise sediment control BMP
Revise erosion control BMP
Revise post-construction storm water BMP
14.
Are all areas where construction has temporarily
ceased (and will not resume for more than 2 weeks)
temporarily stabilized?
Topsoil & seed
Install mat/mulch/polymer
Cover with tarp/plastic sheeting
15.
Are all areas at final grade permanently vegetated
Topsoil & seed
or stabilized with other treatments?
Install mat/mulch/polymer
Sod
Install stone base
16.
Have temporary sediment controls been removed in
areas of the site that meet the permit definition of
‘final stabilization’?
Water to establish vegetation
Repair or reseed areas
Remove temporary practices
Photo No.
1
Date:
Direction Photo
Taken:
Description:
Photo No.
2
Date:
Direction Photo
Taken:
Description:
**Example, continue to add Photolog for weeks 3, 4, 5 ect. to end of project.
EXAMPLES OF SITE PLAN AND EROSION CONTROL PLAN
08/2014
08/2014
CURB CUT/CULVERT PERMIT
Department of Public Works
City of Green Bay, WI
Date:
Applicant Phone:
I/We, ,
hereby request (s) permission:
To remove curb as per diagram and hard surface (concrete or bituminous concrete) the apron,
— OR —
To have the City of Green Bay install a culvert and agree to pay for all costs thereof or to place
said charges on the City tax roll against the property described below.
Address: ,
Lot , Block , Subdivision.
Said work to be done under the supervision of the Director of Public Works and subject to his/her orders.
It is further stipulated with the City of Green Bay, on the part of the applicant, that the provisions of all
Municipal Code of Ordinances of the City of Green Bay regulating the excavation and/or damaging of
streets will be fully complied with.
The driveways shall be located in accordance with the following:
Single–family or two–family dwelling(s). The attached sketch.
Other than single–family or two-family dwellings. The site plan that was approved
on: .
Applicant Signature
Director of Public Works
PRIVATE APRON CONSTRUCTION DETAIL (WITH EXISTING CURB)
CITY OF GREEN BAY SIDEWALK AND DRIVEWAY REQUIREMENTS
If you have questions, please contact City of Green Bay Engineering Department (920.448.3100).
I:\DeptData\PubWorks\Eng\Personnel\Job Reference Guide\Engineering Technician - Concrete\Sidewalks\Permit Handouts\Sidewalk and Curb Cut Inspection.docx updated 7/31/2018
INSPECTIONS: Sidewalk, Driveway, and Curb Cuts
1. All concrete sidewalks and driveway aprons must be inspected by DPW before concrete is poured.
2. The contractor must notify the City of Green Bay Engineering Department (920.448.3100) 48 hours prior to
the needed inspections.
3. Prior to inspection, the concrete forms must be in place and property pins be exposed for review. The
sidewalk shall be 6” from the property line into the Right-of-Way.
4. The contractor/owner must have a representative on site for the inspection.
5. Curb cuts and reconstructed curb will be inspected at the time of the sidewalk inspection.
6. Concrete placed within the City Right-of-Way must be stamped with the contractor’s approved stamp.
7. All sidewalks must meet federal ADA requirements.
8. Any sidewalks not inspected before concrete is placed will be ordered to be removed and replaced at
owners cost if the sidewalks do not meet the City of Green Bay Standards and Specifications or Federal ADA
Requirements.
SPECIFICATIONS: Sidewalk and Driveway Construction
1. Concrete used in the construction of sidewalks and driveways shall be Grade A air-entrained or Grade A-WR
air-entrained from an approved supplier. The maximum slump shall be 3 inches.
2. Equipment and tools necessary for sidewalk and driveway construction shall be satisfactory as to design
capacity and mechanical condition for the purposes intended.
3. All sidewalks and driveways within the street right-of-way shall be constructed on a compacted base of 4-
inch crushed aggregate base course.
4. The foundation shall be formed by the excavating or filling to the required elevation. The constructed
foundation shall be mechanically tamped or rolled until thoroughly compacted to ensure stability.
5. Forms shall be of wood or metal; be straight and of a depth at least equal to the depth of the sidewalk (4”)
and driveway (6”); be sufficient strength to resist displacement during the process of depositing and
consolidating the concrete; be securely braced and held firmly to the required line and grade; be
sufficiently tight to prevent the leakage of mortar; and be thoroughly cleaned and oiled before the concrete
is placed against them.
6. The concrete shall be placed on a moist foundation, deposited to the required depth, and consolidated and
spaded sufficiently to bring the mortar to the surface, after which it shall be struck off and floated with a
wooden float. Before the mortar has set, the surface shall be steel toweled and brushed. The brush shall be
drawn across the surface at right angles to the edges of the sidewalk or driveway with the adjacent strokes
slightly overlapping, producing a uniform, slightly roughened surface with parallel brush marks.
7. The concrete shall be cured with an application of an approved linseed oil membrane forming emulsion at
the rate of 200 square feet per gallon of curing compound.
8. After the concrete has been cured, the spaces along the edges of the sidewalk and driveway shall be
backfilled to the required elevation with topsoil and restored with seed.
9. Sidewalk and driveway construction/reconstruction to be according to attached City-provided details,
(Urban Driveway Sidewalk Adjacent to Curb 602-D-08A, Urban Driveway 602-D-09A, Reconstruct Curb 603-
D-03, Sidewalk Closure Detail)
Signature: ________________________________________________
Date: ________________________
*FILL OUT ONLY IF NEEDED FOR CONSTUCTION ITEMS IN RIGHT-OF-WAY*
(dumpster, porta potty, material, etc.)
TEMPORARY RIGHT-OF-WAY OBSTRUCTION PERMIT
City of Green Bay • Department of Public Works
100 North Jefferson Street, Room 300 • Green Bay, WI 54301 • (920) 448-3100
APPLICANT INFORMATION
Applicant Name:
Organization:
Mailing Address:
City:
State:
Phone Number
On Site Phone Number
Zip Code:
OBSTRUCTION INFORMATION
Obstructed Street: At Address Number:
From Street: To Street:
For partial street closure, which side of the street will be obstructed? (Check all that apply):
North South East
West
Portion of street to obstruct (Check all that apply):
Travel Lane(s) Parking Lane(s) Terrace Sidewalk Parking meter(s) Alley
(Meter fees will apply)
Purpose of Obstruction (Check all that apply):
Cable Gas Sewer
Water Electric Telephone / Communication
Dumpster / Storage Material delivery Material / Equipment Storage
Other
Located on arterial street system or within 500 feet of a signalized intersection: Yes No
Obstruction allowed between 7:00 AM – 9:00 AM, and between 3:30 PM – 6:00 PM: Yes No
Start Date
End Date
Start Time
AM
End Time
AM
PM
PM
SPECIAL PROVISIONS
Notes/
Comments
Date Issued Date Expires
Extended To
Excavation Permit #:
TERMS AND CONDITIONS
* THIS PERMIT (OR COPY) SHALL BE DISPLAYED ON THE DRIVER'S SIDE DASHBOARD OF ALL OBSTRUCTING VEHICLES *
The applicant herein shall comply with Section 9.27 of the City of Green Bay Municipal Code of Ordinances and also assumes all responsibility for any claim of damage
against the City caused by such obstruction. The applicant hereby agrees to provide traffic control devices according to the latest Manual on Uniform Traffic Control
Devices and its State of Wisconsin Supplement and is liable for all damages for failure to install and maintain suitable and correct traffic control devices.
THIS
PERMIT IS SUBJECT TO REVOCATION IF UNFAVORABLE TRAFFIC CONDITIONS DEVELOP DURING THE PERIOD THAT OBSTRUCTION IS PERMITTED
OR IF INCORRECT/IMPROPER TRAFFIC CONTROL DEVICES ARE USED.
Applicant (Signature & Date) Director of Public Works (Signature & Date)
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Form 967 New Home Construction (City of Green Bay)

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Completed 16 July 2020

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