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Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE fety and Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Starts. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 11-and 2-family dwellings. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide may be used by other government agency programs[Privacy Law,s. 15.04(1)(m)]. <br /> 4x. <br /> PERMIT APPLICANT. <br /> Last Name First Name Middle Initial <br /> Street Address <br /> City State Zip Code Telephone Nc.(include area code) <br /> 171t;- �5-S� 2XI <br /> PROJECT:LOCATIOR <br /> Building Address Subdivision Name Lo # Block # <br /> Legal Description Parce No. <br /> Wk 1/4, NW 1/4, Section 30 T 40 N, R 17W E or W 36-4430-01-500 <br /> A; PROJECT TYPE 21 PROJECT HVAC EQUIPMENT ::,. <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel (Elec.) ❑ Heat Pump <br /> n 2 Family E] Boiler Central AC E] Other: <br /> Other: <br /> 3.:P.lROJEC7.ENERGY SOURCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ El El El 11 <br /> Water Heating E:1 El El 11 1:1 El <br /> 4, PROJECT CONSTRUCTION TYPE 5,PROJECT FOUNDATION <br /> Site Constructed E] Concrete 19 masonry E] Treated Wood <br /> ❑ Manufactured E] Other(specify): <br /> A..PROJECT AREA .7. ESTIMATED PROJECT BUILDING COST.'­�:��:��i!i�i <br /> : <br /> Li vin area = Oe-) Square Feet $ <br /> I present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101.65, Wis. Stats. I understand the Uniform Dwelling <br /> Code, Chapters ILHR20-25,still applies toall new 11-and 2-family dwellings and must be omplied with. I realize <br /> the issuance of this permit does not relrie me of�cpliance with other applicable codes and ordinances. <br /> L, 015 <br /> Applica s i4nature Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUING JURISDICTION' M Town E] Village E] City ❑ County of: Union <br /> MUNICIPALITY NUMBER: # 0 7 - 0 3 6 Where Dwelling Located FEES: NonB <br /> PERMIT ISSUED BY: Burnett County Zoning DATE ISSUED <br /> S8DB 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />