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Wisconsin'Departmentof Industry, WISCONSIN ADMINISTRATIVE Sa etyand Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7) & 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide may be used by other government agency programs[Privacy Law,s. 15.04(1)(m)j. <br /> PERMIT APPLICANT <br /> Last Name First Name Middle Initial <br /> 7YO P, <br /> Street Address <br /> �iOC) p � CIC( Mhz- r o`- iq <br /> City State Zip Code Telephone No nclude area code) <br /> C �-C�/ <br /> jv, /3 7 &12 <br /> pitQJl CT t oCA N <br /> Building Address Subdivision Name4L20t Block # <br /> g� . ✓a� �� CSM V.14 P.924 <br /> Legalscription Gov't. Lot 4 1/4, 1/4, Section _�T 37 N. R 1Rw F or 02-340 <br /> 7, PROJECT TYPE 2. PROJECT HVAC EQUIPMENT <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel (Ele(.) ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 3. PROJECT ENERGY SOURCE Nat.Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ N ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> 4, PROJECT CONSTRUCTION TYPE 5. PROJECT FOUNDATION <br /> Site Constructed ❑ Concrete Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ other(specify): <br /> 6. 'PROJEC'fAREA 7. ESTIMATEDPROJECTBUILDIN COST <br /> Living area = Square Feet $ <br /> I present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101.65, Wis. Stats. I understand the Uniform Dwelling <br /> Code, Chapters ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be c mplied with. I realize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes arid ordinances. <br /> Applicant's ignature Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUING JURISDICTION' n Town ❑ Village ❑ City ❑ County of: Trade Lake <br /> MUNICIPALITY NUMBER 0 7 - 0 3 4 Located Dwellin FEES: Non <br /> PERMIT ISSUED BY: Burnett County Zoning DATE ISSUED:'' 9/5/95 <br /> SBD9 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant Q <br />