2008/10/01 - SANITARY - SAN - Other

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APPLICATION FOR REVIEW PETITION FOR VARIANCE SBD-989OX -Complete all pages- Safety& Buildings Division This page may be utilized for fax appointments Bureau of Integrated Services Complete and indicate date plans will be in our office 1. Facility Information Complete for, confirmed appointments': Facility(Building)Name: Transaction ID: Number and Street Zin Previous Related Trans.to: Commerce Site Number(if known): Assigned Reviewer: Legal Description: Assigned Office: Review Start Date': County of'. ( ) O Village O Town of: `Submittal must be received in the office the appointment no City later than 2 working days before the confirit med a000inlment. NOTE: Personal information you provide may be used for seconda purposes[Privacy Law s. 15.04(1)(m),Stats. 2.Owner Information Customer# 3.Designer Information Customer# Name /nar IC lire k o,2 Designer Rick //o a/ci n.5 Company Name _ Design Firm Ne /c y Gra- c / � .f S.rhs Y— Number and Street Number and Street dl97 sfanF.ed /¢"e A774O33— City, State,ZipCode City,State,Zip Co �S�{c✓ wS Sy$4 S ff. Pia,,. I to N SS/O.S Contact Person Contact Person Telephone Number Fax Number Telephone Number Fax Number G d - 3.1 8- 6 673 71.5= d d b- eJ/-s 7 4. Plan Review Status Plan previously review by(please enclose a copy of review letter) 34 Plan submitted with petition 0 State 0 Municipality O Approved 0 Held D Denied I7 Plan will be submitted after petition determination Code Being Petitioned D Requesting revision D Other: 0 Building 0 HVAC 0 Plumbing CI Private Sewage System Commerce Transaction Number 0 Swimming Pool D Electrical 5. State the code section being petitioned AND the specific condition or issue you are requesting be covered under this petition for variance. 7'ud /& 93. 4'3. 6. Reason why compliance with the code cannot be attained without the variance. 7h e Life /s 5- e n fir.//y .r.n 's(a 01 'lh a t'//<A e w y / /r an iceyo wsA N%�yL Tir< an/y 0,49a /th S r+ 6/e s tl / es hca eh /z nei LK � n N a e F v C<ef-nFe�iak� 64aP Fe�h a eas>< 7. Slate your proposed means and rationale of providing equivalent degme of health,safety,or welfare as addressed by the code section petitioned. jolt ab erb fon ce//i Con be /eufes a f ,G r xln+ai</ S'0 re,r{- FNen. '", C AIWr en eACA ,J l a+'1he A r s ,t / F ' Vz✓'+%<o.f stn eNa-1 ren %s 70FP.above oNw a/e.-afi ar B. List attachments to be considered as part of the petitioner's statements (i.e., model code sections,test reports,research articles, expert opinion, previously approved variances, pictures, plans,sketches,etc.). /Y/a p s a ,Ss r/ c. es CA e/- .VERIFICATION BY OWNER-PETITION IS VALID ONLY IF NOTARIZED WITH AFFIXED SEAL AND ACCOMPANIED BY REVIEW FEE Note: Petitioner must be the owner of the building or system or credential applicant for a Comm 5 petition. Tenants,agents,designers,contractors, attorneys,etc.,shall not sign petition unless Power of Attorney is submitted with the Petition for Variance Application. f (-I<. ('O d ,being duly sworn,I state as petitioner that I have read the foregoing petition and I believe Petitioner's Name(typ r print) it is true and that I have significant ownership rights to the subject building or project. Subscribed and sworn Nota mion e Public My comssixpires Petitioner's Signal to beF r n e thi dale Q -30 VC Com let Cher side for va anc a bests from Comm 20-25 and Comm 61.65 - MAKE CHECKS PAYABLE TO DEPT.OF COMMERCE TOTAL AMOUNT DUE $ d. ey Attach check here. 11tPvn4uAP2.0''10(1)ICh k....r b,iw,klglLrews nuns v�.vair rv5JIMI1_:Funn.hmLfor Weniu,vi curreia version of lhic lona)