JURISDICTION :
PROJECT TYPE :
PERMITS :
PARCEL NUMBER :
NAME :
ADDRESS , ,
CONTACT ,
DWELLING CONTRACTOR
LIC/CERT # : EXP DATE :
HVAC CONTRACTOR/QUALIFIER
ELECTRICAL CONTRACTOR
ELECTRICAL MASTER ELECTRICIAN
AREA SQ. FT.
1 OR MORE ACRES SOIL WILL BE DISTURBED false
LOCATION :
Description
BUILDING
ADDRESS : , ,
COUNTY SUBDIVISON LOT NO. BLOCK NO.
ZONING
DISTRICT : PERMIT NUMBER :
SETBACKS Front ft.: Rear ft.: Left Ft.:Right ft.:
1. PROJECT TYPE :
2. AREA :
AREA INVOLVED (SQ FT)
Unit 1
Unit 2
Total
3. OCCUPANCY :
4. CONSTRUCTION TYPE :Site Built Mfd. Per WI UDC Mfd. Per US HUD
5. STORIES :1-Story 2-Story Plus Basement Other
6. ELECTRIC : Entrance Panel Amps , Underground, Overhead
7. WALLS :Wood Frame Steel ICF Timber/Pole Other
8. USE :Seasonal Permanent Other
9. HVAC EQUIP :Furnace Radiant Based Heat Pump Boiler Central AC Fireplace Other
10. SEWER : ,
11. WATER :
12. ENERGY SOURCE :
13. HEAT LOSS :
14. EST. BUILDING COST w/o LAND :
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.
SIGN/PRINT NAME:
DATE [ 8/25/2025 6:09 PM ]