Fillable Wisconsin Uniform Building Permit Application (City of Markesan (WI))

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Wisconsin Uniform Building Permit Application (City of Markesan (WI))

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Wisconsin Division
of Safety and Buildings
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 Tel.
Contractor Name & Type Lic/Cert# Mailing Address Tel. & Fax
Dwelling Contractor (Constr.)
Dwelling Contr. Qualifier The Dwelling Contr. Qualifier shall be an owner,
CEO, COB or employee of the Dwelling Contr.
HVAC
Electrical
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 SteelOther:
13. HEAT LOSS
Unfin.
Mfd. per WI UDC  ICF
Bsmt
Mfd. per US  Timber/Pole
10. SEWER
___________________________ BTU/HR Total Calculated
Living
HUD  Other: Municipal Envelope and Infiltration Losses (available from "Total
Building Heating Load" on Rescheck report)
Area
5. STORIES 8. USE
Sanitary Permit#
Garage 1-Story Seasonal
_______________
Deck/
Porch
2-Story Permanent
11. WATER 14. EST. BUILDING COST w/o LAND
Other: Other: Municipal
Totals Plus 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 reverse side of the last ply 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 Village of City of County of State→ 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
7RWDOBBBBBBBBBBBBBBB
*(&)(( 
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
Construction
HVAC
Electrical
Plumbing
Erosion Control
_____________
Name____________________________________
Date ____________ Tel. ____________________
Cert No. __________________________________
SBD-5823(R11/11) Distribute: Ply 1 – Issuing Jurisdiction; Ply 2- Issuer forwards to state w/in 30 days; Ply 3- Inspector; Ply 4- Applicant
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:
lf 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
inquiry 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 neglÍgence
of the contractor
that
occurs
in connection with the
work
preformed
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
preformed
under
the building
permit
or because of any
bodÍly
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
preformed
under
the
building
permit.
Additional
Responsibilities
for
Orvners
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:
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Wisconsin Uniform Building Permit Application (City of Markesan (WI))

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Completed 13 July 2020

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