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Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor 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 /> SEEINSTRUCTIONS 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)]. <br /> .. ..... .. <br /> Last Name first Name <br /> Middle initial <br /> 1/6 <br /> GeoR6L � /V <br /> Street Address <br /> City State Zip Code T lephone No.(include area code) <br /> OR 6 7/5) Y6 3 el..J— <br /> x: .. .... <br /> X. <br /> N:: .. .......... <br /> Building Address Subdivision Name Lot# Block # <br /> —/,70 9sCSM V.13 P.112 I I <br /> LegarD—escription UOV 'r LoFt Parcel No. <br /> 1/4, 1/4, Section 28 T 37 N, R 18W E or W 34-1528-03-305 <br /> 9 "PROJCCT TYPE 2. PROJECT"VAC EQUIPMEN <br /> 1 Family Forced Air Furnace E] Radiant BaseboardorPanel (Elec-) L] Heat Pump <br /> ❑ 2 Family F-1 Boiler ❑ Central AC E] Other: <br /> :OJKfENERGY 1SQURt Nat.Gas L.P. <br /> Oil Elect. Solid Solar <br /> Space Heating 0 11 0 El <br /> Water Heating El <br /> 4. ..7....... ... ... <br /> .......... <br /> ;PROJECT CONSTR0 <br /> E jiU <br /> E] Site Constructed XConcrete ❑E] Masonry El Treated Wood <br /> Manufactured 0 Other(specify): <br /> 6. RROJECTARI«A 7. ........... <br /> 77.....—... <br /> ESTIMATED PR : ECT RU <br /> ... ......... <br /> Living area Square Feet $ 4*3p, &0,0 0 /,00 .OU <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 I-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 /> PA cant's 50,tjnature 5- 3 -- f,7 <br /> P Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUING J PRISDICT.IOW, Town El Village E] City El County of: Trade Lake <br /> NUMB Where Dwelling <br /> S, <br /> MUNICIPALITY ER-. :: # 0 7 0 3 4 Located +EE None <br /> PERMIT ISSUED BY: Burnett County Zoning Office <br /> DATE ISSUED.-] 5/20/97 <br /> SBDB 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />