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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin q <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 /> ............ "�g gz?� <br /> W: i W 1'11gi <br /> Last NFirst Name Middle Initial <br /> e R o c <br /> 1 Street Address <br /> boa q 5—e 6lue <br /> City State Zip Code Telephone No. (Include area code) <br /> 5-q-zlW-39" <br /> Building Address Subdivision NameLot# Block# <br /> -7 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section TN, R E or W <br /> '-F <br /> WN2 <br /> 1 Family El Forced Air Furnace Radiant Baseboard or Panel 13 Heat Pump <br /> 11M 0", <br /> L� 2 F=iily 0 Boiler 0 Central AC 0 Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 0 0 <br /> Water Heatin 0 0 0 <br /> Nl <br /> I'M/ <br /> Site Constructed Concrete 0 Masonry 0 Treated Wood <br /> 0 Manufactured to the WI UDC; not U.S. HUD code) 0 Other(speci <br /> M, 77 <br /> WN <br /> p <br /> Ow N <br /> Ax"I.. "M <br /> Living area= I0o 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. 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 I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this t(does not relieve me of c7liance with other applicable codes and ordinances. <br /> pp icant's SiDate Signed <br /> MUST BE COMPLETED By THE MUNICIPAL ITV BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY aD BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> WNVIIINI�K'11�1�Q, <br /> # L <br /> IM: <br /> Big/1/wIt <br /> I LI/ <br /> SBD-8254 (R.2/00) Distribution: 0 Ply I-Issuing Jurisdiction 0 Ply 2-Municipality Forwards to State If New Dwelling 0 Ply 3-Applicant <br /> ISSUING JURISDICTION <br />