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rerMIL Vib­iYl <br /> Wiscohsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. See instructions on back of yellow copy. <br /> 0� <br /> INtA <br /> !"TAP .4-T <br /> Last Name First Name Middle Initial <br /> Street Address <br /> R_02 0,15-P-, 'Oe�e"Al I <br /> City State Zip Code Telephone No.(include area code) <br /> Building Address Subdivision Name Lot# Block <br /> I Tollander Acres 2 <br /> Legal Description Parcei No. <br /> 1/4, 114, Section 23 T 40 N, R 16W E or W 20-4323-03-500 <br /> ........... .... .. <br /> 2 <br /> 2: <br /> 1 Family Forced Air Furnace L] Radiant Baseboard or Panel(Elec.) E] Heat Pump <br /> M 2 Family ❑ Boiler E3 Central AC 0 Other: <br /> 3. PROJECT ENERGYSQLlRCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating Cl ozz ❑ El IJ 0 <br /> Water H ea ti ng ... El" El El <br /> .......... <br /> PRiiICTC+DN <br /> ....... ....... <br /> SIR <br /> Rr Site Constructed ❑ Concrete gmasonry C] Treated Wood <br /> E] Manufactured rl Other: <br /> 6. El <br /> ( <br /> CT AREA 7. <br /> LivinQ area = ? Square Feet $ 7,5' <br /> I present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101.65, Wis. Stats. I understand the Uniform Dwelling <br /> Code, Chapters ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. Irealize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> (7— - :3��=/tle C? <br /> icant's Signature 1117 Date)Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> lulms URIS nnkinnd <br /> J1 Town E] Village ❑ city of: <br /> MUNICIPAL! NUM-Ofkv # u 7 0 None <br /> �:� 2 0 ... .. <br /> PfRMlTtSStJlrl)BY. Zoning Office 00iTEI$S.U;, 9/11/92 <br /> SBD 8254 IN 09/89) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />