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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> muiicipalities for new 1- PERMIT APPLICATION Safety and Bpildings 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 /> ° `x.1 a w as <br /> y^ i q°e.,,�C�''°x""",;,�,h`r'{ew.,Ya}�-"t4 ('xYi �'..#'., a'txe,' a—sxd:,w,ey srr u+8" e.�,�`p�, " <3. °^ew.:•aa� kM5e*}�*.�Lx!&° ._�.ai#.k0iFh�3r7 1 axy,„ <br /> Last Name�� e++a> <br /> "w <br /> >. <br /> First Name Middle Initial <br /> ��j ft 13 rid <br /> Street Address <br /> CityG State Zip Code Telephone No. (Include area code) <br /> Z <br /> pow <br /> IRM <br /> a a Axa r •°.; ®Z'i!§d �� r`� Y r }� � <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parce No. <br /> 1/4, 1/4, Section T _trd N, R�E or W .,,., �e¢ <br /> f ^r n,l <br /> � <br /> x 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel �' Heat Pump <br /> ❑ 2 Family ❑ Boiler ® Central AC i�5 ❑ Other: <br /> ENERG' ' '' �. °s"w�.i. <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ �1 ❑ ❑ ❑ ❑ <br /> Water Heating ❑ 19 ❑ ❑ ❑ p <br /> 4. CONSTF' NDATION <br /> IN Site Constructed D9 Concrete 6.9-� ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6. AREAATED BUILDINGYCO � 7�°x <br /> Living area= "l- 3 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 /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIV ION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTION. Town ❑ Village ❑ City ❑ County of: <br /> MUNICIPALITY NU1w1 )t # Q - D :° <br /> of Dwelling Location <br /> PERMIT ISSUED,BY: j_ TRE y <br /> jR <br /> ISS <br /> SBD-8254 (R 4/99) <br /> ISSUING JURISDICTION <br />