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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin ;,/_�kl;�_ <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 FLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last Name <br /> WName Widdle0nitial <br /> I/I6"�,M5 �Us� ► n /�( <br /> Street Address <br /> 3 '7 95 fore,<J a lv <br /> City State Zip Code Telephone No. (Include area code) <br /> Noy+k 6(Ultck M 55 0-5 Co Cis'-67q- a syr <br /> 'Slw'ir 4 K M h i1i <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parcel No. <br /> 1/4, S)SL 1/4, Section j-a_T �LN, R E or py> <br /> ,G.S" ,;is r7x 4 <br /> s z <br /> ' .. .- .. ,,. _. ... z - _.._,: -- „_,.yw: x..r,.r..'::, •. 1,,,.n 1,f,�,�� <br /> 19 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler DK Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> <<4 V s r••�� ,? x 6 ,rta'r '»i ,15 "., 'ar41 N in r aV v n rLt»1R, 1,18'M 9n. rrr 5 s 4 s g d <br /> z " t #tiny✓*rx� +a',� 5dxtF. <br /> i� <br /> » i, z.. ✓1+ <br /> » ,.,.. <br /> Site Constructed ❑ Concrete ❑ Masonry Treated Wood <br /> ❑ Manufactured to the WI UDC; not U.S.HUD code) ❑ Other(s ecif ): <br /> 15 d <br /> r51 a 2", ,y i{ii7 L"a xb K�3»jz1 ""` 'ass z✓t3 br1 ' r yr r 'n ,', <br /> a,Bs:'p5L r x <br /> tkr: . <br /> ml � +lT <br /> DU <br /> Living area= 30 Square Feet Iq db $ <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 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> 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 MUNICIPALITYABEFORE FORWARDING PLY 2 TO THE STATE DIVISION UE SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> SBD-8254 (R.2/00) Distribution:❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applican <br /> ISSUING JURISDICTION <br />