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CITY OF OSHKOSH No
OSHKOSHBUILDING PERMIT - APPLICATION AND RECORD
ON THE WATER
PAT DAWLAK
Job Address4630 SHAMBEAU DROwnerCreate Date12/15/2003
DesignerContractorSCHUMANN CONSTRUCTION
Category110 - New Single FamilyPlanE1-159-1203R
TypeBuildingSignCanopyFenceRaze
R-1
ZoningClass of Const:8SizeIRRG
Sq. Ft.Projection
Unfinished/Basement1460Rooms7Height20Ft.
Finished/Living
1460Sq. Ft.Bedrooms3Stories1Canopies0
Garage624Sq. Ft.Baths2Signs0
Poured ConcreteFloating SlabPierOther
Foundation
Concrete BlockPostTreated Wood
Occupancy PermitRequiredFlood PlainNoHeight PermitNot Required
Park DedicationRequired# Dwelling Units1# Structures1
NSFR/ New single family, 2 car attached garage and a 6' x 44' front deck/ porch and a "L" shaped 8' 34' deck wrapping around the rear of the
Use/Nature
house.
of Work
HVAC ContractorMARX MECHANICALPlumbing ContractorKOCH PLUMBING
Electric ContractorBELL ELECTRIC
Fees: Valuation$200,000.00Plan Approval$75.00Permit Fee Paid$680.00Park Dedication$200.00
12/18/200300/00/0000
Issued By:DateFinal/O.P.
Permit Voided
In the performance of this work I agree to perform all work pursuant to rules governing the described construction.
While the City of Oshkosh has no authority to enforce easement restrictions of which it is not a party, if you perform the work
described in this permit application within an easement, the City strongly urges the permit applicant to contact the easement
holder(s) and to secure any necessary approvals before starting such activity.
SignatureDate
Agent/Owner
1077 STATE RD 26OSHKOSHWI549040000231-7820 - disconnected
Address-Telephone Number
To schedule inspections please call the Inspection Request line at 236-5128 noting the Address, Permit Number, Type of
Inspection (i.e. Footing, Service, Final, etc.), Access into Building if Secure (how do we gain entry), your Name and Phone
Number. Unless specified otherwise, we will assume the project is ready at the time the request is received. Work may
continue if the inspection is not performed within two business days from the time the project is ready.
GRADE STAKE FORM
OSHKOSH
Grade Stake Number7080
ON THE WATER
NamePAT DAWLAKAddress4630 SHAMBEAU DRCreate Date12/15/2003
Block
Lot14Ward
SubdivisionIsland View EstatesZone
Sidewalk Existing
Street NumberLot Dimensions
Building Grade Elevation Stakes Set At Site12/16/2003Set By D.W.G. BK - 593 , P - 25
Department of Public Works
I, the undersigned, owner or agent of the above described property agree to have the grade established before excavation
has commenced.
Wisconsin Department of Industry,
WISCONSIN UNIFORM Application No.
Labor and Human Relations
BUILDING PERMIT
0105788
Safety and Buildings Division
P.O. Box 2509
Parcel No.
APPLICATION
Madison, WI 53701-2509
Wisconsin Statues 101.63, 101.73
PERMIT REQUESTED üü ConstrHVAC
ElecPlbgOther:
üü Erosion
Owner's NameMailing AddressTelephone No.
PAT DAWLAK1219 KENTUCKY AVEOshkoshWI54901-0000
Contractor:
üü ConElecHVACPlbg
Mailing AddressTelephone No.
Lic/Cert #
SCHUMANN CONSTRUCTION1077 STATE RD 26WI0
249359 OSHKOSH54904-231-7820 - disconnected
Contractor:Mailing AddressTelephone No.
Con üü ElecHVACPlbg
Lic/Cert #
BELL ELECTRICWI0
171765 1303 Midway RdMenasha54952-920-886-6589
Contractor:Mailing AddressTelephone No.
ConElec üü HVAC
Plbg
Lic/Cert #
245277 OSHKOSHWI54904920-235-6510
MARX MECHANICAL4535 STATE ROAD 91-6304
Contractor:Mailing AddressTelephone No.
Con
ElecHVAC üü Plbg
Lic/Cert #
KOCH PLUMBINGOSHKOSH54902-0
2005 DOTY STWI920-231-6661 or 235-0282
Lot Area
PROJECT LOCATION
1/4,1/4,Section,TN,RE(or)W
Sq. ft.
Building AddressSubdivision NameLot No.Block No.
4630 SHAMBEAU DR14
Island View Estates
Zoning District(s)Zoning Permit No.FrontRearLeftRight
Setbacksft.ft.ft.ft.
1. PROJECT3. OCCUPANCY6. ELECTRICAL9. HVAC EQUIPMENT12. ENERGY SOURCE
üü New üü Forced Air Furnace
Nat.L.P.OilElec.SolidSolar
üü Single Family
Entrance Panel
Repair
Fuel
Gas
*
Two FamilyRadiant Baseboard or Panel
amp
Alteration
200
Size:
Raze
Garage üü
Space Htg
Service:
Heat Pump
Addition
Move
Other (print):Overhead
üü
Water Htg
Boiler
üü Underground
Other: üü Central Air Conditioning
*Dwelling unit will have 3 kilowatt or
4. CONST. TYPE7. FOUNDATION
Other
more installed electric space heating equip.
Concrete
2. AREA INVOLVED
üü Site Constructed
10. PLUMBING
Infiltration control option is:Full sealing
Masonry
Manufactured
Unfinished
Sewer
of joints.Blower door test.Exterior
Treated Wood
Basement1460Sq. ft.
air infiltration barrier.
üü Municipal
5. STORIES
Other
13. HEAT LOSS (Calculated)
üü 1-Story
Septic
Living Area1460Sq. ft.
8. USE
26842
EnvelopeBTU/HR
Permit No.
2-Story
624
GarageSq. ft.
Seasonal
17870
InfiltrationBTU/HR
Other
11. WATER
üü Permanent
14. EST. BUILDING COST
üü Municipal Utility
Other
$217,000.00
Plus BasementPrivate On-Site Well
The applicant agrees to comply with all applicable codes, statues and ordinances and with the conditions of this permit, understands that the issuance of
the permit creates no legal liability, express or implied, on the Department or municipality; and certifies that all the above information is accurate.
APPLICANT'S SIGNATURE
DATE SIGNED
This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or
APPROVAL CONDITIONS
revocation of this permit or other penalty
SEE "STANDARD CONDITIONS OF APPROVAL" SHEET
State of:
TownVillage üü CityCounty
Municipality Number of Dwelling Location:
ISSUING
7 0 - 2 6 6
City Of Oshkosh
JURISDICTION
PERMIT(S)WIS. UNIFORM PERMIT
FEES:PERMIT ISSUED BY:
ISSUEDSEAL NO.
üü Construction
Plan Review$75.00
JOHN ZARATE
Name
HVAC
Inspection
Electrical
Wis. Permit Seal$30.00
12/15/03
Plumbing
Date
üü Erosion
Other
70330
Cert. No.
306829
$105.00
Total
SBD-5823 (R. 07/92)
PARKLAND DEDICATION FEE COLLECTION RECORD
OSHKOSH
ON THE WATER
Job Address 4630 SHAMBEAU DRDate12/18/2003
NamePAT DAWLAK
Address1219 KENTUCKY AVEOshkoshWI54901
SubdivisionIsland View EstatesLot14
Building Permit Number0105788
Number of Dwelling Units1Number of Structures1
Fee Required$200.00Fee Paid
Owner's SignatureDate
Inspector's SignatureDate
20 '-0"
/
~5.02'