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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 /> r , <br /> e <br /> Last Name First Name Middle Initial <br /> W k're 1fve <br /> Street Address <br /> .q1� Y-1, se, <br /> City State Zip Code Telephone No. (Include area code) <br /> 1`1Pjf � ( SSEi /y (l/.2 X79 / 33'9 <br /> � 0 <br /> Kim <br /> Building Address Subdivision Name Lot# Block# <br /> aR IF`1 5P1R1 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R E or W <br /> I Family 81 Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler 9 Central AC ❑ Other: <br /> �y <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ® ❑ ❑ ❑ ❑ <br /> �`tOS�1 Water Heating ❑ ® ❑ p ❑ ❑ ❑ <br /> � . � €T°. "No&4, ?� a 4 <br /> ATI N ' 41NO <br /> NIS <br /> - Site Constructed 19 Concrete El Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 777777-77—, <br /> 6.AREA 7.6 ESIATEDBU" <br /> � <br /> Living area= Square Feet $ io)00 o — <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 /> 4�l W ' _§n4 .27— od <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALI Y EFORE FORWARDING PINK PLY TO THE STATE DIVI ION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTI4I�I. . <br /> Town ❑ Village ❑ City ❑ County of: <br /> MUNICIP'ALI l ,.F $ - —�- <br /> of Dw0fing Locatim 'hF <br /> PERMIT ISSIJED;BY. 3 <br /> SBD-8254 (R4/99) <br /> ISSUING JURISDICTION <br />