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�t,�)33(-Q1 <br /> S,..�mit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <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 /> & 4° R,t .€i +a� '. r <br /> P <br /> u"Apra«a%n,$eX r s 4 i �' . 3.�'� z _ 1. 19, <br /> .a <br /> Last Name First Name Middle Initial <br /> A'Z1rheRAC '.ei T. <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> wa6odmems's/ 73 8- 9yY� <br /> ' 4n'.>.'.t a i € v"r9",x¢ �`+� �P� x e <br /> PRUJEC I oA e x <br /> Building Address Subdivision Name Lot# Block# <br /> /,5o <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R E or W <br /> PRC "�pst: .� ) � "31C=BQ[1 ' IL1T ` e ' <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> ENERGF 5 )t + rp .a p Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ 1 ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ,1S( ❑ ❑ ❑ ❑ <br /> y <br /> 4. CONS + FOUI�fDATION - r <br /> .,,59x," ..... <br /> JK Site Constructed jff Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6.AREA "7 ESTIMATED BUILD! ,0S'I , <br /> Living area Square Feet $ / (d Oo b , <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 re ieve me of compliance with other applicable codes and ordinances. <br /> • �/�'�'/ oZoca <br /> Applicant's S' ture Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTION: Town ❑ Village ❑ City ❑ County of: <br /> MUNICIPALITY°Ni31WIBEls # b - o� FEES:° <br /> of Dwelling Location �— <br /> PERMIT ISSUED,BY: <br /> sSUED <br /> : <br /> SBD-8254 (R4/99) <br /> ISSUING JURISDICTION <br />