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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of WiscAilf'`sxs-s— <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 /> Last Name First Name Middle Initial <br /> S�GIkvle') At_v­ <br /> Street Address <br /> —r s a y c� �e►� �Wt <br /> City State Zip Code Telephone No. (Include area code) <br /> 6pKDAc �' wIN SSrZS 777- � 37s <br /> Building Address Subdi7 <br /> vision Name Lot# Block# <br /> CS � rf� � CVel <br /> Legal Description /I// Parcel No. <br /> 1/4, 1/4, Section T ( N, R�E or W <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> .❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heatin ❑ ❑ ❑, 0: ❑ 2.- <br /> ite Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured to the WI UDC;not U.S. HUD code) ❑ Other <br /> Livin area <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 petmit do not relieve me of co pliance wi other applicable codes and ordinances. <br /> A licant's Signature Date Si ed <br /> MUST BE COMPLETED BY THE MUNICIPAL BEFORE FORWARDING PLY 2 TO THE STATE DI"IO OF SAFETY AND BUILDINGS <br /> Town ❑Village ❑ City ❑ County of: <br /> # <br /> SBD-8254 (R.2/00) Distribution:❑Ply 1-issuing Jurisdiction ❑Ply 2-Municipality Forw s to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />