Free Petition for Building Code Variance- F-62537 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62537 (Rev. 01/09)

STATE OF WISCONSIN Page 1 of 3

PETITION FOR BUILDING CODE VARIANCE INSTRUCTIONS
Completion of this form is required by COMM 3.03(2) to request a variance from a building code or for approval of alternative design, which is not in strict conformance with the letter of the code but meets the intent of the code. (This form is the equivalent to the Department of Commerce form SBD-9890.) A variance is not a waiver from a code requirement. The petitioner must provide an equivalency which meets the intent of the code. Pictures, sketches, and plans may be submitted to support equivalency. If the proposed equivalency does not adequately safeguard the health, safety, and welfare of building occupants, frequenters, firefighters, etc., the variance will be denied. Failure to provide adequate information may delay the petition. A petition for variance does not take the place of a required plan review submittal. NOTE: A separate petition is required for each building and each code issue petitioned.

Petition Checklist
The Division is unable to process variance petitions that are not properly completed. Check the following items for completeness before submitting the petition: · Petitioner's name (typed or printed) · Petitioner's signature · The Petition for Building Code Variance must be signed by the owner of the building or system unless a Power of Attorney is submitted. · Notary Public signature with affixed seal · Analysis to establish equivalency, including any pictures, illustrations, or sketches of the existing and proposed conditions to clearly convey your proposal to the reviewer. · Proper fee · Any required position statements by fire chief or municipal official

Position Statement
Position statements must be completed and signed by the appropriate fire chief or municipal enforcement official. Signatures or seals on all documents must be original. Photocopies are not acceptable. Fire Safety Issues: A position statement from the local fire department is required. Non-Fire Safety Issues: A position statement is not required for non-fire safety issues such as plumbing and energy conservation. Barrier-Free Petitions: Position statements from both the local fire department and municipality are required. Rules Relating to One- and Two-Family Dwellings: Only a position statement from the municipality is required.

Standard and Priority Reviews
A standard review will be scheduled and processed in approximately 30 working days. A priority review is scheduled and processed in approximately 10 working days and costs twice as much as a standard review.

Fees
The fees for review of the petition for variance are as follows: Standard Review 30 Working Days COMM 61-66, Commercial Building Code All Other Chapters $500 $250 Priority Review 10 Working Days $1,000 $500 Revision * $100 $100

* Revisions are only accepted for one (1) year after action on the original petition.

Payment Make check payable to: Division of Quality Assurance Contact Information
If you have questions about completion of this form, call (608) 261-5993. Submit the notarized Petition for Building Code Variance form, a check, and supporting documentation to the following address: FIRST CLASS MAIL Bureau of Technology, Licensing and Education Division of Quality Assurance P.O. Box 2969 Madison, WI 53701-2969 DELIVERY SERVICE Bureau of Technology, Licensing and Education Division of Quality Assurance 1 West Wilson Street, Room 950 Madison, WI 53702

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62537 (Rev. 01/09) Check No.

STATE OF WISCONSIN Page 2 of 3 OFFICE USE ONLY

PETITION FOR BUILDING CODE VARIANCE

Check Date Check Author

REVIEW TYPE Standard(30 Day)

Date Submitted Priority(10 Day)

Total Amount Submitted

I. Facility Information
Name ­ Facility or Building Address Name - City, Village, or Township City Village Township County Zip Code Facility License / Provider Number

II. Owner Information
Name ­ Owner Address Name ­ Contact Person Telephone Number Name ­ Company City Fax Number State E-mail Address Zip Code

III. Designer Information
Name ­ Designer Address Name ­ Contact Person Telephone Number Name ­ Designer Firm City Fax Number State E-mail Address Zip Code

IV. Plan Review Status
Plan submitted with petition Plan Project No. Plan will be submitted after petition determination. Requesting revision Other Identify the code section and the specific condition or issue being petitioned for variance. Plan Previously Reviewed By (Enclose a copy of the review letter.) State Municipality Code Petitioned Building HVAC Approved Plumbing Held Electrical Denied

Explain why compliance with the code cannot be attained without the variance.

Explain the proposal to provide an equivalent degree of health, safety, or welfare as addressed by the code section petitioned.

List attachments to be considered (i.e., model code sections, test reports, research articles, expert opinion, previously approved variances, pictures, plans, etc.).

V. Verification by Owner
NOTE: Petitioner must be the owner of the building or system or credentialed 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 Building Code Variance form.

Subscribed and sworn to before me on: I, _________________________________________________ ,
Name ­ Owner or Power of Attorney (Print or type.)

NOTARY SEAL

Date (Month / Day / Year)

being duly sworn, state as petitioner that I have read the petition and believe it is true and that I have significant ownership rights to the subject building or project. SIGNATURE ­ Owner or Power of Attorney Date Signed

SIGNATURE - Notary

Name ­ Notary (Print or type.)

F-62537 (Rev. 01/09) Name ­ Owner . Project Address City Project Number Zip Code

Page 3 of 3

VI. Fire Department Position Statement
Complete the following for variances from COMM 61-66, COMM 10, COMM 16 and other fire related requirements. I have read the Petition for Building Code Variance and recommend (Check appropriate box.) Approval Conditional Approval Denial No Comment

Explanation for Recommendation Identify any conflicts with local rules and regulations and explain suggested conditions.

Name ­ Fire Department Address Name ­ Fire Chief or Designee (Print or type.) SIGNATURE ­ Fire Chief or Designee City

Notify of Petition Outcome Yes State Zip Code No

Telephone Number Date Signed

VII. Municipal Building Inspection Recommendation
Complete the following for variances from COMM 20-23. Also to be used for COMM 16, electrical petitions, if COMM 61-66 plan review is by municipality or orders are written on the building under construction; optional in other cases. Submit a copy of the orders. I have read the Petition for Building Code Variance and recommend (Check appropriate box.) Approval Conditional Approval Denial No Comment

Explanation for Recommendation Identify any conflicts with local rules and regulations and explain suggested conditions.

Name ­ Municipality Exercising Jurisdiction

Name ­ Municipal Official (Print or type.)

Telephone Number

Address

State

Zip Code

SIGNATURE - Municipal Official

Date Signed