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.,;,snit 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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> PI!RMIT APPLICANT, <br /> Last Name First Name Middle Initial <br /> E_D <br /> Street Address <br /> 5074 <br /> City State Zip Code Telephone No. (Include area code) <br /> n o urJ2)5 vig:txu S"!5/12 �,l Z 78q-- 8 3c8 <br /> AOjECT- LOCATION <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R / E or W <br /> 1. PROJECT TYPE , 2.HVAC EQUIPMENT <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 3,ENERGY SOURCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ .9 ❑ ❑ ❑ ❑ <br /> 4. CONSTRUCTION TYPE 5.FOUNDATION <br /> Site Constructed A Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6.AREA 7. ESTIMATED BUILDING COST <br /> Living area= QO Square Feet $ 00. 006 <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/ILHR 20-25,still applies to all new I-and 2-family dwellings and must be complied with. I understand that the <br /> issuancn11KLW_-e ermit 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 DIVISIQN OF SAFETY AND BUILDINGS <br /> ISSUING JijRISDICTION. Town ❑ Village ❑ City ❑ County of: <br /> MUNICIPALITY Nt*0kR: # A - C7 (� BEES: -6-- <br /> 9f Dwglling Location <br /> PERMIT ISSUED BY &021 <br /> rSSIrE <br /> SBD-8254 (R.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />