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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION <br /> and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) Safety and Buildings 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 /> = I'I:IC ' <br /> tP <br /> Last Name ' <br /> First Name Middle Initial <br /> Street Address d Ca <br /> vV > CQe f3 1) '� <br /> City State Zip Code Telephone No. (Include area code) <br /> wcc, /I fh <br /> 77777777777 <br /> 1tCI <br /> d �"� 9..'Nrvq» o� gx,{,°M.w. .k "^I $ at 3 �e�r �i"' ;tri.R��4� pi w �+ rv��� a o <br /> Building Address �� , <br /> Subdivision Name Lot# Block# <br /> Legal Description <br /> (� 1/4, 1/4 Parcel No <br /> Section �_T /�..QN R�( _E or(Z) <br /> C1 p <br /> -�, � <br /> 1 Famll 3�#!-, , .�r �f#a �:".�35 .�'c'm^t�.r�`s �.,` ., ,. t� <br /> Y 1131Torced Air Furnace ❑ Radiant Baseboard or Panel <br /> ❑ Heat Pump <br /> ❑ 2 Family El Boiler El Central AC ❑ Other: <br /> A <br /> ' SOc Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ 211� ❑ ❑ <br /> Water Heating ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ <br /> TIONN TYPE '5. OT7I ATION <br /> ite Constructed loncrete ❑ <br /> ❑ Manufactured Masonry ❑ Treated Wood <br /> ❑ Other(specify): <br /> AREA <br /> r�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 mm/ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> iss ce of thi permit do s not elieve me of compliance with other applicable codes and ordinances. <br /> App icant-s Signature <br /> Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPAL EFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> SUI1�iG Town ❑ Village ❑ City ❑ County of: <br /> liNICIPALI3 YAlUM3ER: <br /> eti'bweliingLuca�on # C�-- <br /> PERMIT ISSUES BY: <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Y Yellow-Applicant <br />