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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> �i//i--iAtr iii N..brb iml ex i ori-0id@ria n" a r€>v�a' �i e w � , ar ¢i( E15¢r bwaa(� 3iw i <br /> TRAP IJI-AN <br /> Y A 4 <br /> Last Name First Name Middle Initial <br /> "tQ <br /> Street Address <br /> City State I Zip Code Telephone No. (Include area code) <br /> -T-VNK '-1 Grdve. IMn 550766 57- 051 Iv <br /> i rca r'iro � r iw �ai m @'u i� a rMa�t ASC an i s !iio H <br /> w y�y A� r.» .. •, wm a r.t. <br /> � <br /> Building Address Subdivision Name Lot# Block# <br /> E.c.si YelIaw Q%vcr fz<Q. Powc1ur) R„ter 1pjllr .d 5$ i <br /> Legal Description Parcel No. <br /> 1/4, �J JF 1/4, Section -7 T _y�N, R E or �O$'Q Q <br /> X. e_ a,.r � c+aae -�,.r ,r x r r .e r <br /> aril a,�m�- �».: �.�7 «�d.&«r w�,e� iP wm er a s 6 � a � <br /> p w e k a w ua i' e»X r <br /> O•� �^ ,��s ..'-' _7n t .fie ', ''. & �.� J,C'fiisi .�i°r 17n��il ti lir � s . <br /> 9 1 Family ® Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ® Central AC ❑ Other: <br /> �.rm <br /> ENE RGY� �a , „ �� ,� .. ,�, Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ N ❑ ❑ ❑ ❑ <br /> Water Heating ❑ 0 ❑ ❑ ❑ ❑ <br /> w r a 11111x" 161s .am it�v}�e <br /> 4. CONSTRVCZIQN TYPE &FOUNDATION <br /> _ <br /> ❑ Site Constructed N Concrete ❑ Masonry ❑ Treated Wood <br /> 19 Manufactured ❑ Other(specify): <br /> &AREA .XS Ir 1A > ll B k `9 OST <br /> Living area= 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/ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> cy ' �l6l <br /> Applicant'4 Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING AW � Town ❑ Village ❑ City ❑ County of <br /> . _ ,194 -.04 <br /> VCK — <br /> MUNICIPALITY� UMBER: <br /> of Dwolling Location <br /> PERMIT ISSUED BY: DATE <br /> 11 <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />