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aq <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin �s f <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 /> IM <br /> Last Name <br /> First Name Middle Initial <br /> f✓ ,u <br /> Street Address City State Zip Code Telephone No. (Include area code) <br /> so7a9 •7/s= a�e- <br /> a NOW , <br /> <, <br /> Building Address Subdivision Name Lot# Block# <br /> 9 <br /> Legal Description Parcel No. <br /> /V 1/4, W W 1/4, Section Ly T N, R A� E or W <br /> 1 Family ❑ Forced Air Furnace 19 Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> Water Heatina ❑ ❑ ❑ ❑ ❑ ❑ <br /> ® Site Constructed ® Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC;not U.S. HUD code ❑ Other(specify): <br /> Living area= 7 Square Feet $ 07 (ro-�• a-o <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 compliance with other applicable codes and ordinances. <br /> Q 7- 1112- <br /> Applicant's <br /> 112-A licant's Signatuie Date Signed_ <br /> MUST BE COMPLETED BY THE MUNICIPAL BEFORE FORWARDING PLY 2 TO THE STATE DIVISIO OF SAFETY AND BUILDINGS <br /> Town ❑Village ❑ City ❑ County of: <br /> # ,�_ <br /> � �� tt-� <br /> SBD-8254 (R.2100) Distribution: DPIy 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />