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INSTRUCTIONS <br /> Th,e owner, b 7nr or age t� shall cornplet(' rid p-ovf u a:l required A)!,,ration or, the appfiotio:r <br /> form down through the S gnalute of Applicant olncK_ 'e; ilat� ,s used for statewide statistical <br /> gather,-)g on new one- and two-family dwelling;, as vt-eil as fu� local administration. When <br /> completed,submit to local rnunicipal ity having jurisdiction. <br /> PERMIT REQUESTED: <br /> • Fill in building address. <br /> • Fill in legal description of lot, subdivision name, lot number and block number <br /> PROJECT DATA: <br /> • Fit in all numbered project data blocks (1-7: wl,h thr- req,ired 'nforrnation ALL DATA <br /> BLOCKS MUST BE FILLED IN, INCLUDING THE FOLLOWING: <br /> Type •.'irk only ,. ',rr`i'f" r, '_Family' if n,...;r vV .,! is i�elnq bunt in other words, <br /> ae i � 'juin c i .,� ; a�_`�« �ragF� e - g bu 'I, evars I s:•rves . %,i4 <br /> or two fcmlly dwelling <br /> if Ir ?i V�d�er', a ,1 . . r 'F 3 Fes cj�' t <br /> a single-family dwelling. <br /> ? HVAC Equipment - Check only the major source ur heat, riot any supplemental sources. <br /> Mark -centra air coruiitioning it pre-'ent O iiy e`„ck "Radiant Baseboai ” <br /> there is no central source of heat <br /> 6- Living Area include any fni;hed area includir g 'inised areas in basements. <br /> For two-family dwellings, Include total combined areas <br /> 7. Estimated Cost- include the total cost of construction, but not cost of land or landscaping. <br /> SIGNATURE: <br /> • Sign and date application form. <br /> e- r <br /> ISSUING JURISDICTION: <br /> • This must be completed by the AUTHORITY HAVING JURISDICTION. <br /> Check off MUh'!CIRAtITY STATUS, suci� as town, village, city or county <br /> till in MUN�C nAI.ITv rtiUMBER O "J✓t . ' .NG nCA' SON + issued by a rouoty, indirate <br /> '_hE.spr.;ific tr ipaity number;n t-ere='f:e dwelling r� l bs built <br /> of pe,< f. suim, Hermit and date h dl.dir j permit swed. <br /> RETURN PINK COPY WITHIN 30 DAYS AFTER ISSUANCE TO'. <br /> DILNR-Safety&Buildings Division <br /> P.O. Box 7969 <br /> Madison,WI 53707 <br />