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;Ii pARilIF t,J
<br /> STATE OF WISCONSIN
<br /> (1r0 Application for Review, Petition for
<br /> Department of Safely and -Complete all pages-
<br /> s'ji Professional Services Variance
<br /> ,r SSlll '
<br /> Industry Services Division Use this page for fax appointments(fax 877-840-9172)
<br /> NOTE: Personal information you provide may be used for or email to: dsassbplanscheduleaa.wi.gov
<br /> secondary purposes[Privacy Laws. 15.04(1)(m),Slats.] Indicate date plans will be in Industry Services office
<br /> 1. Facility Information Complete for confirmed appointments*:
<br /> Facility(Building)Name: -.OMt Transaction ID: _
<br /> Number and Street Zip: Previous Related Trans.ID:
<br /> SPS Site Number(if known): Assigned Reviewer: f
<br /> Legal Description: Assigned Office:
<br /> County of: Review Start Date*:
<br /> ❑ City ❑ Village ❑ Town of: *Submittal must be received In the office of the appointment no later than
<br /> two working days before the confirmed appointment.
<br /> 2.Owner information Cu tom[er# 3.Designer Information Customer#
<br /> Name ' VW4 ((c fiP �So Designer 6/2V r(ch P) f
<br /> Company Name /�1 ( y ( C 4 t , LLB) Design Firm b , ,� „l n LLC
<br /> Number and Street/\��t3 Ul`i N Number and Street 1 f
<br /> 22.313 5a4'A, C1kt~tt � O9 IMilil.SIi'i' 434 '2s t
<br /> City,State,Zip Cod City,State,Zip Code
<br /> il M x
<br /> Contact Person `f+ t ( ,4 f{�) NI Contact Person j2 p J,j_
<br /> Telephone Number t� tEmail, Telephone Number ( Email.Addr ss
<br /> ‘,04-3)/5-101 2 'ii`P. t sak e /Wit, e4,1 MR-1Y5-io tp . n+ is ' ia�. .
<br /> 4.Plan Review Status Plan previously review by(please enclose a copy of review letter)
<br /> SI Plan submitted with petition _State _Municipality _Approved _Held _ Denied
<br /> Plan will be submitted after petition determination Code Being Petitioned _Commercial Building _HVAC _Plumbing
<br /> _ Requesting revision _ Other: ✓Private Sewage System_ Swimming Pool _Electrical _Flammable Liquids
<br /> SPS Transaction Number _Amusement Rides_Uniform Dwelling Code _Boilers _Elevators
<br /> _Gas Systems_Refrigeration _Rental Weatherization _Other:
<br /> 5. State a code sectio ein petitioned AND the specific condition or ssue you are r questin a covered uglier this petition for variance
<br /> s flr�OLI?skrcri L S.67-. p1 - 5 r- txrfal S sits
<br /> 7-14.47-140T- SANK me l* w‘ , (crcPo4 Nt
<br /> 6. Reason why compliance with the code cannot be attained without the variance(Attach additional sheets,if necessary)
<br /> f'i 5e 4 .It-
<br /> P,`i ''' d /' 1 Pl i�' 'i &S� j f. 'C INNAL45 /1,44, 61ilims (94444c.
<br /> Tot, ro, a}4k. w/Pa01 Pai3(gymv fro) , 0 mucv nuturvo4 rft s t711 ..
<br /> 7. State your proposed means and rationale of providing equivalent degree of health,safety or welfare as addre sed by the code section petition
<br /> 7i►�, I S L'o Sq buff . Git 1aiu. t iiS0,6 t1 4 Fitz TYPE ,41>r)-$6S Pull f tbs'r of ..
<br /> A+-Y ka 6A (IN Svey 84 5441-Ae-4.), ~ os- s t, iwt r 6i-CrAZ 74K , Malt L fr- 2!o itwm3
<br /> 8. Li t atta •ents to b- sidered .art of to- .• 'tioner's : -ments ., . odel co ction , reportrs,researara les,a opinion,
<br /> p vi. sly a.. _--.veil. :: ,pictur- ans,ske •. etc.).
<br /> tAl k- 1,,f t Ut r .tF Cc.41 S g•" -'1 64./E- 7s,4044- (eat. AIL Jest4-04f,J-04f, 11 I'IPc •6 -
<br /> Verification by Owner-Petition is Valid Only if Notarized with Affixed Seal and Accompanied by Review Fee
<br /> �►Eb %t ►H�
<br /> Note: Petitioner must be the owner of the building or system or credential applicant for a SPS 305 petition. Tenants,agents,design
<br /> attorneys,,etc.,shall not sign petition unless Power of Attorney is submitted with the Petition for Variance Application. NOTARY PUBLIC
<br /> STATE OF WISCONSIN
<br /> Y/A 1 !T / >. 0 ,being duly swom,I state as petitioner that I have read the foregoing.patitionand I baliovo
<br /> Petitioner's Name type or print) it is true and that I have significant ownership rights to the subject building or project.
<br /> Petitioner's Signature:_., = _ Subscribed taand sworn to Notary Public My commission expires
<br /> before me ts„datep
<br /> Make Checks Payable to:State or Wf=DSPS or ❑ invoice Designer,who will be personally responsible for payment. Total Amount Due
<br /> Designer: $ 300,0o
<br /> Signature Attach check here.
<br /> Complete other side for variance from SPS 320-325 and SPS 361-366
<br /> Owner's Name Project Location Plan Number
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