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RECEIVE® <br /> DEC 2 7 2016 <br /> •c-:� <br /> STATE OF WISCONSIN Application for Review Petition tiDUSTRY SERVIt'r' <br /> pages- <br /> Departmentmp tete au]" of Safe <br /> Prfessional ServicesCo <br /> and <br /> . for Variance <br /> Industry Services Division Use this page for fax appointments(fax 877-840-9172) <br /> NOTE: Personal Information you provide may be used for <br /> secondary purposes[Privacy Law s.15.04(1)(m),Stats.) Indicate dale plans will be In Industry Services office <br /> 1, Facility Information Complete for co firmed appointments*: <br /> Facility(Bullding)Name;_ L Transaction ID; <br /> Number and Street S Z Previous Related Trans.ID: <br /> SPS Site Number(If known): Assigned Reviewer: ( -A • \hr <br /> Legal Description: <br /> 3 _ Assigned Office: <br /> / T <br /> - �� , � ��••11 <br /> County of: S�ti k/ Review Start Date*: <br /> *Submittal must be received In the office of the appointment no later than <br /> ❑ city ❑ Villageown of: two working dove before the confirmed appointment, <br /> 2.Owner lnl rmatlan customer# 3.Dosic nor Information Customer# <br /> Name Designer ' <br /> Co an aft a Design Firm <br /> i <br /> Number and street Number and Street <br /> city,S A40deezu� City,Slate,Zip Code <br /> Contact Pers6n i t„ I Q r t I Z Contact Person <br /> ti '<.JlXR7� <br /> Tel a Ger :Fax Number Telephone Number Fax Number <br /> y <br /> 4.Plan Review Status Plan previously review by,(please enclose a copy of review letter) <br /> _ Plan submitted with petition _Stale _Municipality_Approved _Held_ Dented <br /> _ Plan will be submitted after petition determination Code Being PetitionedCommercial Building _HVAC'_Plumbing <br /> _ Requesting revision _ Other, _Private Sewage System_ Swimming Pool _Electrical _Flammable Llqulds <br /> SPS Transaction Number. _Amusement Rldes_Uniform Dwelling Code _Boilers _Elevators <br /> _Gas Systems_Refrigeration_Rental Weelherizalion _Other. <br /> 6. Pate the d ll g tl d ANf the sp dfl IUo sy9 you are re eilgg by cove d under his p titian for variance. � <br /> • I C I <br /> 8, Re so y compllance wi tl a code cannot be attained without the varlnce(Attach additional sheets, mace ry) <br /> tAIM , <br /> 7, State your proposed means and rationale of providing equlvalent degree of health,safety;or welfare as addre sed by the code section pelilloned, <br /> 0. List attachments to be considered as part of the pelillonses statements(Le.,model code sections,test reports,research amidpexnpeFrte�hful <br /> ` Ini . L .eviously approve rarlancog,pictureplans skst .es,elf.):/ <br /> ec <br /> Veriflostlo by Owner•Petition Is Valid Only If Notarized wlth Affixed Seal and Accompanied by Review Fee <br /> Note: Petitioner must be the owner of the building or system or credential applicant for a SPS 305 petition. Tenants,agents,dablgn ,con r <br /> attorneys,etc„shall not sign petition unless Power of Attomsy is submitted with the Petition forVadance Application, 1 (JL I C <br /> L 0.e �� ct lu being duly swom,I state as petitioner that I have read the foregoing pet yon and I bell�� HAM <br /> �1 tar Mfi <br /> Pet8loneh Name or do It Is true and that I have significant ownership his to the subject but or tib/!C <br /> Petltbn rs S ature Subscribed and swom to Notary Public My I <br /> before me this dale on <br /> �$C <br /> Make Checka Payable to:Stat of WI— SPS or ❑Invoice Designer,who will beperae responsible&payment Total Amount Due <br /> Signature Attach check here. <br /> Complete other stria tor•varlanea from SPS 320.325 and BPS 361-366 <br /> Owner's Name Prolect Location Plan Number t <br /> rrrch�.�l wAltz;K <br /> (807.14) <br /> 5p? <br />