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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin �`SoZr'I <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) <br /> SEE INSTRUCTIONS ON BACK OF SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> La Name First Name Middle Initial <br /> ZqP/ `occ.s14 , <br /> Street Address <br /> ,),2 ed <br /> City State Zip Code Telephone No. (Include area code) <br /> �a2bCL w fC_ <br /> IMENNNEEMEEM <br /> Building Address Subdivision Name Lot# Block# <br /> 6d 7 ,� <br /> Legal Description /� Parcel No. <br /> 1/4, 1/4, Section T _�N, R 1 4e E or W <br /> &a, ME °„an. ~\ 'S'a•>,RiMi,a .`r Fix;, 'IIE ct.E:1 <br /> 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 FaI'llmily ❑ Boiler ❑ Central AC O-Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ 93,00, ❑ ❑ ❑ ❑ <br /> Yx: ,J =` +,r ?� °.:: 1"r *2" �W�a i �l✓r > <br /> Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured to the WI UDC; not U.S.HUD code) ❑ Other(s eci �11,1f ): <br /> a b *y '� r +lwki"iii xu n r r,j .. J r „' <br /> rx ri :'�i1 <br /> tOWN <br /> All <br /> Living area dy 0 Square Feet $ r e�ov-e <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPAL TY)BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> 111, Town ❑Village ❑ City ❑ County of: <br /> 6 <br /> SBD-8254 (R.2/00) Distribution:❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />