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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings <br /> and 2-family dwellings (Wis. Stats. 101.63 (7) &,161.65 (3)) Division <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)l <br /> PERMIT APPLICANT <br /> Last Name First Name Middle Initial <br /> A4 a To a re- <br /> Street Address if <br /> Pt , 75-A- <br /> City State Zip Code Telephone No. (Include area code) <br /> 6 v ss Yb �n 5SO 3�a <br /> FRt)JEC"I LOcTION <br /> Building Address Subdivision Name Lot# Block# <br /> Ta bo•- Zak--e- 0/'P,, Csrn vj p, a 3 <br /> Legal Description R �E or® P O- 0No. l <br /> 1/4, S�' 1/4, Section / T <br /> 1 PROJECT TYPE 2.1'RITJEIrT HVAC E IIIPMEN <br /> ❑ 1 Family IT Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> PRQJECT E i eQOgQ�i, Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ L�1 ❑ ❑ ❑ ❑ <br /> A <br /> Water Heating <br /> A 11 El El <br /> ROJCJN7RRUCTI0N E 5PROJEC. WQ. DA1ON <br /> Site Constructed ❑ Concrete ❑ Masonry Treated Wood <br /> ❑ Manufactured ❑ Other ec. <br /> PRCJJECT AREA 7R ESTIMATE I}PROJECT BUILDING C. ST <br /> Living area= c;�y X 10 Square Feet $ <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. <br /> I understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm/ILBR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with I understand that the <br /> issuance o 's permit does not r e of c ce with other applicable codes and ordinances. <br /> licant's Si tur . Date Signed <br /> MUST BE COMPLETED BY THE MUNICIP AEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUINGJURIS�DICTIUNs Town ❑Village El city El County o£ <br /> C� <br /> ul+rlAA ;I NUMBERI Min <br /> : <br /> PST ISSUEII BY: � DATE <br /> SBD-8254 (R 08/97) White-Issuing Jurisdiction Pink-State Within 3ff Days Yellow-Applicant <br />