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=#7 d,--5 <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 YELLOW COPY. <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 /> US v i <br /> Street Address c' <br /> City State Zip Code Telephone No. (Include area code) <br /> ' Lw. .I,Oca' ©fie. <br /> Building Address a,9 Subdivision Name Lot# Block# <br /> Legal Description Y'(1 , ?� �. )(� Parcel No. <br /> 1/4, 1/4, Section T N, R E or <br /> 1 I*RO T PF e>. WjE�,( UiP i'ylI` <br /> Ei-I Family 2Torced Air Furnace ❑,., Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler a.,/Central AC ❑ Other: <br /> 3.ENERGY, OUR Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> 4. CONSTRUCTION TYPE 5 FOUNDATION <br /> V�Site Constructed ❑ Concrete Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> G AREA 7 ESTIMATED BUILDING COST <br /> Living area= OD Square Feet 1 $ ?o I opo <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 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance f this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPAL Y EFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JfJRILm -4ON Town ❑ Village ❑ City ❑ County ( D v <br /> t t-E�h <br /> MUNICIPALITY NUMBER: # — D SES: <br /> of Dwelling Location lTI <br /> PERMIT IssuEn <br /> c> n�L4 ssuD.'' ? <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />