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CR <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 PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> r <br /> Last Name First Name Middle Initial <br /> R/( <br /> Street Address <br /> /3jo <br /> City State Zip Code Telephone No. (Include area code) <br /> c./d Is oPki 5q01 l5 - 38(�- 5-e9 (c> <br /> Building Address Subdivision Name Lot# Block# <br /> 9-/0 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section _T _N, R Q_E or W ., <br /> r4 �. <br /> .,:,. 1n..»x.n^n..v.1 x"'f M,�.;•^ trv,••,�S ..Sir l:f .fi..a;: <br /> l Family 01-forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Fgamil ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ Cly-- ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> r e jja� <br /> ri'' <br /> n <br /> 4 �y <br /> ❑ Site Constructed P-Concrete ❑ Masonry ❑ Treated Wood <br /> -H(-Manufactured(to the WI UDC, not U.S. HUD code) ❑ Other(s ectf ) <br /> Living area= 14 H 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 rmit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> WSTTED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: - <br /> SBD-8254 (R.2100) Distribution:❑Ply 1-issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />