of Safety and Buildings
Wisconsin Uniform Building
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)]
Constr. HVAC Electric Plumbing Erosion Control Other:
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.
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 Permit No.
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
2. AREA INVOLVED (sq ft) 4. CONST. TYPE
Wood Frame Fireplace
Unit 1 Unit 2 Total
Site-Built Steel Other:
13. HEAT LOSS
Mfd. per WI UDC ICF
Mfd. per US Timber/Pole
___________________________ BTU/HR Total Calculated
HUD Other: Municipal Envelope and Infiltration Losses (available from "Total
Building Heating Load" on Rescheck report)
5. STORIES 8. USE
Garage 1-Story Seasonal
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 ________________
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.
Town of Village of City of County of State→ State-Contracted Inspection
Municipality Number of Dwelling Location
____ ____ - ____ ____ ____
PERMIT(S) ISSUED WIS PERMIT SEAL # PERMIT ISSUED BY:
Wis. Permit Seal
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