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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconssiin�73 3 <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 FLY <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 /> N <br /> � <br /> G <br /> o <br /> Street Address <br /> j0 �L}- (L- <br /> City State Zip Code Telephone No. (Include area code) <br /> 014- qoc>5 <br /> W. <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description �,���I Parcel No. <br /> 1/4, 41/4, Section K-� T N, R E or W <br /> !m's"' <br /> AA S <br /> dleyy+ <br /> 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ 0 ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> a <br /> Site Constructed ❑ Concrete ;K Masonry ❑ Treated Wood <br /> ❑ Manufactured to the WI UDC;not U.S. HUD code) ❑ Other(s ecif ): <br /> Living area= Z OQ 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. 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 permit does not relieve me of complianc with other applicable codes and ordinances. <br /> 4 , 3 <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALI EFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑Village ❑ City ❑ County of: <br /> SBD-8254(R.2/00) Distribution: OPly 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />