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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin#- �a <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 /> xw` <br /> Last Name First Name Middle Initial <br /> LAjd Source LL <br /> Street Address <br /> Po 80x cle <br /> City State Zip Code Telephone No. (Include area code) <br /> �C Ce.ij 7X- e /4KJ 6378 3 ao -3,57 - 8 733 <br /> Building Address Subdivision Name Lot# Block# <br /> C7ti2 file— a <br /> Legal Description S iy :37312 Vo( 117 P60 -61 Parcel No. <br /> 1/4, NE 1/4, Section a7 T ! N, R �� E ot�J o3a -S3 a7 -0 / -SYS <br /> `;'L+r�a"�., �: 'X+,tt.. SEC.r,✓`,�i ➢ ', w � 4�, <br /> 1 Family ❑ Forced Air Furnace Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> W,w1i Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ <br /> Water Heatina ❑ J9 ❑ ❑ ❑ ❑ <br /> In <br /> Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC; not U.S. HUD code) ❑ Other(specify): <br /> till <br /> �.a \1";ni ........ <br /> ''"• Ike,\ i <br /> ", I�,1, 4'!t'`�` xsh�, Fs/yp�,x���, �•: <br /> Living area= 78 o 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. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Cmm 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 p does not rel' me of compliance with other applicable codes and ordinances. <br /> 8 a8 D <br /> A licant's Si.mature K�e gjeM )- He err. Date igned <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 /> L' <br /> f.. <br /> SBD-8254 (R.2/00) Distribution: ❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />