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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 /> s die s+��, "9 , .,�fi ' " <br /> ' Mploo <br /> ,°� a a,F <br /> w . t i. .,. <br /> Last Name First Name Middle Initial <br /> �I <br /> 0 U t irk Lx_ 7ti� <br /> Street Address <br /> LX <br /> City State Zip Co�de3Telephone <br /> elephone�No.�(Include <br /> Include area <br /> �co�d�e) <br /> r a . 3 w, <br /> 104 X <br /> Building Address Subdivision Name Lot# Block# <br /> 6 <br /> Legal Description// Parcel No. <br /> YU <br /> 1/4, � 1/4, Section - T N, R 16 Eoro <br /> Pik <br /> `W,' <br /> �l l Family 19 Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 3 ENERGYIE3E+re . .. Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ® ❑ ❑ <br /> 4 CONSTR"UCIUN"TYPE 5�Fbi7NDATION <br /> � . <br /> Site Constructed ❑ Concrete Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Others eci <br /> ( p fY): <br /> 6 AREA fi ESTIMATED BUIIfTNG ZW ' ° <br /> Living area 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. <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 of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> aCA.1.,� �� - A j, C l G -o <br /> Appli ant's Signature a Signod <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTION; Town ❑ Village ❑ City ❑ County of: <br /> MUNICIFALITY NITIVIBEI ;' .-6.1 <br /> of Dwelling Location " s <br /> PERMIT ISSUEDBY: ' <br /> �w26� 12,r>2/4 I� f. 17r . <br /> SBD-8254 (R 4/99) <br /> ISSUING JURISDICTION <br />