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Wisccnsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> J-abor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide maybe used by other government agency programs[Privacy Law,s 1504(1)(m)l. <br /> PI:RMt`i APPLICANT <br /> .......... ... <br /> .......... <br /> X:X <br /> .......... .. .. ... <br /> .. ... ... ... <br /> . ........... <br /> Last Name First Name Middle Initial <br /> M 5 7T <br /> Street Address <br /> City State Zip Code Telephone No.(include area code) <br /> S _s <br /> gT43 9 <br /> ........... <br /> ............... <br /> .......... . ......................x <br /> X.: <br /> .......... ... ... . <br /> ............. <br /> % .::::, .......... <br /> ............... . ..... <br /> .............. <br /> ....... M:x: <br /> Building Address Subdivision Name Lot# Block# <br /> t. C— <br /> LegaTDescription Parcel No. <br /> 1/4, 1/4, Section T _N, R E or W <br /> :.X.::: CT <br /> �1 PRQJE!CT..TYPE2:_:: PRO[E HVAC QUIPME, <br /> El.1 Family Forced Air Furnace El Radiant Baseboard or Panel (Elec.) L] Heat Pump <br /> f:1 2 Family E] Boiler E] Central AC ❑ Other: <br /> :.lPR <br /> OJfC.r1RGY <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> :N:E: SOURCE.�i.:� <br /> Space Heating El I--] El ID 0 <br /> Water Heating ❑ El ❑ 11 El <br /> ................ <br /> 4 ROXCr�C. ONS RCTIO :TYP � ifa...... <br /> OUNDATION <br /> 0 Site Constructed uEE] Concrete masonry E] Treated Wood <br /> ❑ Manufactured El Other(specify): <br /> PROJECTs. :AREA.. 74:ESTIM'ATM 01ECT 1G <br /> Cos?S., .......... <br /> Living area Square Feet $ q,!q t dw <br /> 1 present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101-65, Wis. Stats. I understand the Uniform Dwelling <br /> Code, Chapters ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. Irealize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> _�41_ bl> <br /> /vzz <br /> Applicant's Signa re Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> �i i9� Town E] Village C] City E] County pf7 <br /> ISSUING,JURISDICTION <br /> MUNICIPA ITYNUM t 3 <br /> BE:K� _# Where Dwelling Located :FEE <br /> S. <br /> PERM11T ISSUED BY, &r DIATE-IS59911JEM <br /> SBDB 6254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant AIN <br />