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Wisconsin-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. <br /> SEEINSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide maybe used by other government agency programs I Privacy Law,s. 15.04(1)(m)l. <br /> PERMIT'APPI.I�ANT <br /> ........... ........ <br /> Last Name First Name Middle initial <br /> so'l <br /> Street Address id <br /> City <br /> State Zip Code Telephone No.(include area code) <br /> y_'5>, o <br /> //C5 <br /> 7 <br /> . . .......... <br /> M <br /> .. . ....... <br /> Building Address Subdivision Name Lot# Block# <br /> egal Des"tfuvna�a <br /> n/) Parcel No. <br /> 1/4, 1/4, Section T <br /> 777 �N. R E o(w) 6 <br /> 9 <PROJECT TYRE 2..'0ROJECT <br /> 1.7, <br /> bAL 1 Family KI Forced Air Furnace E] Radiant Baseboard or Panel (Elec.) E] Heat Pum p <br /> D 2 Family El Boiler E] Central AC E] Other: <br /> 3.;PROJEC <br /> TQ <br /> EXEROYS U.R CE�].: Nat. Gas L.P. Oil Elect- Solid Solar <br /> .: <br /> Space Heating El .� El El El E] <br /> Water Heating E] El El <br /> ...................... <br /> 4i : RIDJ c1CONSTRU0014.TYPEI:� <br /> T PR. ON <br /> OJECT <br /> S-Site Constructed E] Concrete RMasonry E] Treated Wood <br /> E] Manufactured E] Other(specify): <br /> 6. PROJECT 777 <br /> tX, <br /> R ...... <br /> A "T UL N <br /> ATW"q#_ T <br /> G COS .............. <br /> Livingarea = 17Z 7- Square Feet $ <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. I realize <br /> 7, ante of i permit does not relieve me of compliance with other applicable codes and ordinances. <br /> pl`l�ca i Tture Designed <br /> COMPLETED <br /> MUSTIB BEFORE SUBMITTING TO DILHR: <br /> ISSUING JURISDICTION. Town El Village El City E] County of: <br /> i <br /> MUNICIPALITY NUM.13M Where Dwelling <br /> # Located TEES.A, <br /> PER.Mff ISSUED BY: . ..... <br /> ZC-,n i I-) DATE:I SSUE'll' <br /> SHDH 6154(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />