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9fi ;)sr((GO <br /> 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 FLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last Name // First Name Middle Initial <br /> 177e /TON t ki <br /> Street Address <br /> q'1 Coa."t . x o�J <br /> City State Zip Code Telephone No. (Include area code) <br /> 42 <br /> Building Address Subdivision Name Lot# Block# <br /> COHy1 li N2 <br /> Legal Description Parcel'No. <br /> 1/4, 11 1/4, Section T S�_N, R_/-41 E or(p) —3) <br /> 3 },o' �iJ <br /> : <br /> Nr 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 FamilZ ❑ Boiler M_*Central AC ❑ Other: <br /> Nat. Gas L.—P./ Oil Elect. Solid Solar <br /> Space Heating ❑ l� ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> x;'Is a�,� °£Emu u+ r { ,i <br /> R t <br /> Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC; not U.S.HUD code) ❑ Other(s ecif ): <br /> ;s <br /> �p G� 01, <br /> „ <br /> �i <br /> Livin 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. 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 no relieve of c mpliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ed Town ❑/Village ❑ City ❑ County of: I <br /> &rnek eu1 <br /> SBD-8254 (R.2JOO) Distribution:❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwar s to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />