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�Vq <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 /> f i s"� 'a e d e d.. e x 4. ,.IAi e "i'rt`PP ,. "•1 <br /> Last N,a[m First N me Middle Initial <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> p, f4�T2 'tH ev �. t fi�k.g m'y I�te 3150.dPGiti MS � IuT»F Jilr� �'i.&}. ry tl <br /> Building Address Subdivision Name Lot# Block# <br /> t—CuA) rY Cy aq�p�o �rry <br /> Legal Description <br /> J t 9�i Q rPV 9" b1U�AnIY and <br /> may not W a f <br /> Leull Nps <br /> g P + '3/T? Sr Parcel No. <br /> 1/4 1/4, S ; <br /> �W" , �� CL GOV _OT 6 cK co � o <br /> Pj <br /> S a <br /> bZC <br /> 1 Family IN Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family <br /> }� j ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ® ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ® ❑ ❑ ❑ ❑ <br /> 4,CONST32C)CTICON 4 r 5Y lr!!OIJ TDATION777-777777 <br /> ® Site Constructed ❑ Concrete 0 Masonry ❑ Treated Wood <br /> B Manufactured 761 r- _Pv-vkS ❑ Other(specify): <br /> AREA �n <br /> "�►„• <br /> Living area= ��� �/�5 loaf 6�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 C /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 s permit does no lieve me of compliance with other applicable codes <br /> and <br /> d ordinances.'/e6 <br /> < / -�" ;z <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALrlWBEFORE FORWARDING PINK PLY TO THE STATE DIVISIQN OF SAFETY AND BUILDINGS <br /> iI7ING Town ❑ Village ❑ City ❑ Countyof: <br /> as ; ^„ <br /> :MtrNIC>€PA 'IT Y a Selo 7& <br /> nfl7wellingLocaCwn <br /> PERMIT ISSUED,.I#Y; � <br /> � r <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />