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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 SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> MW ,M 12;1 M,5/_Nil <br /> Last Name First Name Middle Initial <br /> zr aLA Y\ _Mm- \e_y\e_ <br /> Street Address <br /> 49 S-Pr*% y-\c\ <br /> City 9tate ip Code Telephone No. (Include area code) <br /> e-+0 V\ k0._ Y . 55345 <br /> Subdivision Name Lot# Block# <br /> 05 P el-1 &a 1 <br /> A, 1/4, Section T l Parcel No. <br /> R q(�W) <br /> ON' <br /> I Vi <br /> k <br /> BSA P3 <br /> I Family Q A 6 1 M 0 Forced Air Furnace 0 Radiant Baseboard or Panel 0 Heat Pump 67j;L/f<"C <br /> 0 2 Familx 0 Boiler 0 Central AC [A Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 0 <br /> Water Heating 0 ❑ 0 0 ❑ <br /> 110 W <br /> Site Constructed 0 Concrete 0 Masonry 0 Treated Wood <br /> 0 Manufactured(to the WI UDC; not U.S. HUD code) Other(secifX):6t\cce+e Slab jj_3Aa_c_'ovary,b1p <br /> Ac-E <br /> •,\\ _7� <br /> Wv <br /> F-17; <br /> 0 T' <br /> 37 Living area= Square FeetC) $'?a rLA.126v\ 0 M E—LO <br /> td-rf 0 "x'—io <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 I-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 /> vileidzz - 5_4'aj /:?-o <br /> A!ppl1'qdnt's Signature Date Si ed <br /> COMPLETEDMUST BE BY THE MUNICIPALITY EFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> IX Town 0 Village 0 City 0 County of: <br /> 1,W!�Ivko <br /> q,1-6,3 <br /> SBD-8254 (R.2/00) Distribution:0 Ply 1-Issuing Jurisdiction OPly2-Municipality Forwards to State If New Dwelling El Ply 3-Applicant <br /> ISSUING JURISDICTION <br />