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#21074 <br /> Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labo' and Human Relations <br /> 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)1. <br /> #�EIMI F APPLICANT ;', <br /> Last Name _•First Name eMiidddle Initial <br /> ` <br /> Street Address <br /> S 'tea to Sc_o-t� fir-e-e t <br /> City <br /> State Zip Code Telephone No.(include area code) <br /> cooie�� 4Lf -7 -its-35 c? <br /> I'I7C�JIR�'I'LtKllk'I"IEIN <br /> Building Address Subdivision Name Lot# Block # <br /> O U toy 1 rc'.a%l Xct 3 Or bAUJ _ <br /> Legal Description N LA <br /> 8 30 <br /> C Parcel No. <br /> 1/4, 1/4, Section k� � <br /> T Lit N, R ` J E or w' 32-5219-02-100 <br /> 9'. .PROJ +twC TYP' 2. PROJECT HVA EQUIPMENT <br /> 1 Family LJ Forced Air Furnace ❑ Radiant Baseboard or Panel (Elec.) Heat Pump <br /> ❑ 2 Family ❑ Boiler <br /> EJ Central AC ❑ Other: <br /> PROJ!«CT(ANERGYSOURCE; Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ElWater Heating El El ❑ ❑ ❑ <br /> PRI;lJECT Ct9NSTRt1CTIONYpE 5. PROJECT I"C?UNDATIUN <br /> 'S Site Constructed <br /> Concrete E] Masonry El Treated Wood <br /> ❑ Manufactured <br /> ❑ Other(specify): <br /> 6. PROJECT ARE 4I'MATi D P#t+DJCT Bt1 DtNG' OST <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 complied with. I realize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> �)' �- �'V\ <br /> Applicant s Signature N3Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> JURISDICTI <br /> O <br /> N <br /> : EJ Town ❑ village ❑ City ❑ County of: Swiss <br /> Where <br /> MUNICIPALITY NUMBER: '# 0 7 0 3 2 Located welling FEES. <br /> — — — — _ None <br /> P1:ItM1T ISSUED-BY: Burnett County Zoning DATE ISSU'EDs! 11/5/97 <br /> SBDB 6254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />