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Wisconsin Ciepartment of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Divisior <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)1. <br /> �P <br /> X <br /> PERMIT APPLIA <br /> C INT <br /> cf:R <br /> Last Name First Name Middle Initial <br /> Street Address <br /> 'el <br /> City State Zip Code Telephone No.(include area code) <br /> Building AddressfuLWe 7� Subdivision Name Lot# Block# <br /> I Tollander Acres 6 <br /> Legal Description Parcel W. <br /> 1/4, 1/4, Section 23 T 40 N, R 16W E Or W 20-9400-01-600 <br /> 7777�� t <br /> 1, PROJECTTYPE 2. PROJECT HVAC EQUIPMENT <br /> or Panel (Elec.)1 . E] He at Pump <br /> I Family2'Forced Air Furnace I❑ <br /> — Radiant Baseboard <br /> F-1 2 Family El Boiler FE] Central AC <br /> 11 D <br /> P 0 OURC t Solid Solar <br /> ROJECT ENERGY SOURCE Nat. Gas L.P. Oil Elect. <br /> Space Heating 0 El El <br /> Water Heating 0 El <br /> k.-PROJECTCIONSTIRUICTION.TYPE S.:PROJECT:FDUNDAIIPN:z:lf::j::. <br /> . : <br /> ❑ Site Constructed n Concrete 21 Masonry ❑ Treated Wood <br /> Manufactured E] Other(specify): <br /> Ti.: PROJECT AREA [ <br /> N T. ESTIMATED PROJECT. MD. COS <br /> ......... <br /> Livinq area / e7 U Square Feet $ C, <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 11-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 /> "6'et"J' -b 112— <br /> ApplicanVt Signature Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUING9 JURISDICTION. LSV Town ❑ Village E] City E] County of: Oakland <br /> Where Dwelling <br /> MUNICIPALITY NUMBER: # 0 7 - 0 2 0 Located FEES-. None <br /> PERMIT ISSUED BY: Burnett County Zoning DATE ISSUED.:( 10/17/95 <br /> SbDB 6254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />