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as- /� <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new I- PERMIT APPLICATION Safety and Buildings <br /> and 2-family dwellings (Wis. Stats. 101.63 (7)& 161.65 (3)) Division <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 /> PERMIT APPLICANT'' <br /> :�:��::::777777777 777 <br /> Last Name First Name Middle Initial <br /> Y\Y\ <br /> _9tre_et Address <br /> City State Zip Code Telephone No. (Include area code) <br /> Is, _n <br /> NO ?j <br /> Building VJAddresses Subdivision Name Lot# Block 4'!� 5c <br /> Legal Descriptio7,r- S f -1 q V 6 L n-aG V t Ls U '5S-r__ Parcel No. <br /> (I <br /> 1/4, 1/4, Secti6ft T Lio I <br /> oLOr <br /> AVACIE UIPIKE <br /> 1<.' PROJECT TYPE R . ift <br /> NT <br /> EU I Family Forced Air Furnace ❑ Radiant Baseboard or Panel L1 Heat Pump <br /> 0 2 Eamftfl ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.—P./ Elect. Solid Solar <br /> Space Heating Oil El El 0 ❑ <br /> Water <br /> .4 <br /> OJEJ <br /> WFIRIJCTM�TYPE.PROJECT! 0 <br /> 11 Site Constructed B/Concrete ❑ Masonry ❑ Treated Wood <br /> &/Manufactured ❑ Other(�eecify): <br /> PROJECT AREA... :X:7EST IMA9 TTM <br /> PROJECT ING9,09T , <br /> area= I Square Feet , $ 'ooaoo <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 I-and 2-family dwellings and must be complied with. I understand that the <br /> is of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITYBEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town El Village 0 City 11 County of <br /> -W-11 <br /> V: <br /> Z�Y <br /> 1� Is u n 7/7 <br /> SBD-8254 (R 0&197) White-ming Jurisdiction Pink-State iffithii'40 Days Yellow-Applicant <br />