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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings <br /> and 2-family dwellings (Wis. Stats. 101.63 (7) & 161.65 (3)) Division <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 /> PERlVi1T APPLICANT'. <br /> Last N e First Name Middle Initial <br /> Street Address <br /> l+ <br /> City State Zip CodeTelephone No. (Include area code) <br /> fir, s (f �o,l3 <br /> pRO.IET LOCATION <br /> Building Address Subdivision Name Lot# Block# <br /> V. & '5T G`f Cs- H <br /> Legal Description I Parcel No. <br /> 1/4, 1/4, Section T N, R E or W <br /> I PROJECT TYPE ! �.)�`RO,JE+CT C E TJIPMENT <br /> Family orced Air FurnaceRadiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Familyoiler!A 9 - grCentral AC ❑ Other: <br /> PR0.IECT ENERGY SOURCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water H ❑ ❑ ❑ ❑ ❑ <br /> 4 'R 3JECT CON. <br /> STRVCTI�DN TYPE $ ROJECT F()UNI1.�l�Tl€ON <br /> Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other ec' : <br /> 6 PROJECT SEA 7 ESTTER PROTECT BUli1 ?IlTG COST <br /> Living area= 0 026 Square Feet $�0 <br /> I 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/IL.HR 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 /> A licant Signature Date S ed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> �SI)ICTIONs ❑ Town ❑Village ❑City ❑ County of <br /> 11" 1�TIC�ALIT"Y NUMBERt # - SES: :; <br /> oflm�eUiniklacatan <br /> PERM1lT l( UED BY:': SATE '; <br /> �SSII'Eb; <br /> SBD-8254 (R os/97) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />