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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> In unicipalities 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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> to.�_ _ <br /> 3, "00-- <br /> Last Name First Name Middle Initial <br /> 106:,:55 e t�' ,I <br /> Street Address <br /> / /yo- <br /> City State Zip Code Telephone No. (Include area code) <br /> mou /0 5 5"qcll 'X6-S 67 77— 96 clel <br /> -77777777777 <br /> ,9A <br /> J <br /> Building Address Subdivision Name Lot# Block# <br /> 3o 9,,k3 rezboy 4?kc Ve, <br /> Legal Description Parcel No. <br /> 5 1/4, _5 U) 1/4, Section 1Z T /-!5 E c� W <br /> N, R <br /> `i ld <br /> S <br /> 9v <br /> PT ...... <br /> I Family 0 Forced Air Furnace Radiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Family 0 Boiler Central AC 0 Other: <br /> ySOV <br /> Nat, Gas L.P. Oil Elect. Solid Solar <br /> A <br /> wt <br /> Space Heating <br /> Water Heating 0 0 0 0 <br /> 4. CONSTRUCTION�, _:VCTION T WE 5.FOUNDATION <br /> XSite Constructed 0 Concrete AK Masonry 0 Treated Wood <br /> 0-Manufactured 0 Other(specify): <br /> AREA 7. ESTIMATED BVILIDING,COST <br /> Living area= /4/00 Square Feet $ <br /> 1 vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. <br /> I understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm/lLHR 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 /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTIUNr. �KTown OVillage OCity OCounty of: <br /> MUNICIPALITY NUMBER: FEES: <br /> ofDvvelling Location <br /> PERMIT ISSUED_BY: DA <br /> L111 <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />