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_44-0?,� <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings Divi.,. <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 ... s� ztF1 '4: ""bTkS'r $f�'4 .Rg�.s <br /> ` <br /> ., .,. ._ <br /> .9 <br /> Last Name First Name Middle Initial <br /> Street Address <br /> s� U <br /> City State Zip Code Telephone No. (Include area code) <br /> -ti c-KC� S�/�s3 his - e17,2 <br /> ✓,t` ' ✓ z ,%. "• k Nth NSI <br /> t, <br /> I'IiOJECT �0 �* <br /> �' r"`-..1 a <br /> Building Address Subdivision Name Lot# Block# <br /> Lega Description Parcel No. <br /> Ie_ 1/4, S W 1/4, Section T ,� _N, R _F or W <br /> `_". at�i✓ :.,s.ni �8� r N .t ����'I�M�S.\�. N rss <br /> ❑ 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> a 2 Family I-OBoiler ❑ Central AC ❑ Other: <br /> 3 EN +I iCxY O ��m�� 4� a w':•F Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ B-' 0 ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ma ':pww',+r'Nia <br /> 4 CONSTI0 � ` YP FOUNDATION <br /> ❑ Site Constructed $ eoncrete asonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6.AREA "7. ETED BUIi3ING �'� x <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 /> 1 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 /> Rln � 6-ice oa <br /> Applicant's Signa re Date Signed <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 /> MUNICIPALITY NUM`BEI : # d - d 'FEES:' �. <br /> of Dwelling Location <br /> PERMIT ISSUED BY: . <br /> SBD-8254 (R 4/99) <br /> ISSUING JURISDICTION <br />