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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsinttzs-5 e g <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) <br /> SEE INSTRUCTIONS ON BACK OF SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> film IN i i: ISBN WM , <br /> Last Name First Name Middle Initial <br /> MoNl'd�old <br /> Street Addreli <br /> 8 / 1 (� S7 <br /> city State Zip Code Telephone No. (Include area code) <br /> wh 3-�� ��= InNr ssiio �5� - yb� - g9g0 <br /> Building F s <br /> Address a 15- A)J of-Nf - Subdivision Name Lot# Block# <br /> r�+� ESh <br /> M.INAZJI� G-oo5 1-�(rf I <br /> Legal Descrip ion (� '',,,, Parcel No. <br /> 1/4, 1/4, Section _T N, R E or�. ba. O ,� D <br /> liq <br /> 1 Family id Forced Air Furnace ❑ Radiant Baseboard or Panel ❑/Heat Pump <br /> ❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat.Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ % ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> film ;r <br /> x IM.. a <br /> JZ[ Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC;not U.S. HUD code) ❑ Other s ecif ): <br /> c< <br /> Living area= D <br /> Square Feet $ o <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> r <br /> -an�t <br /> r D — <br /> Applicants Si ature Dae Si ed <br /> MUST BE COMPLETED BY THE MUNICIPAL BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> il <br /> SBD-8254 (R.2/00) Distribution:OPly 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling OPly 3-Applicant <br /> ISSUING JURISDICTION <br />