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Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor and Human Relations <br /> BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submitto non-enforcing municipalities for newt-and 2-family dwellings. See instructions on back of yellow copy. <br /> ............. <br /> A-APl i klltT . . .. .... ... <br /> Last Name First Name Middle Initial <br /> Street Address rr <br /> City state Zip Code Telephone No.(include area code) <br /> 1715 ) <br /> .................... <br /> 0� <br /> En: <br /> .... ... . .. .. <br /> Building Address Subdivision Name Lot# Block # <br /> raoA <br /> LegaFDescri.ption —Parcel No. <br /> SE 1/4, \-SW 1/4, Section T N, R E o aQz q309- D23 <br /> TY <br /> �'P <br /> FQ <br /> E." <br /> PM Nx. <br /> 27�Far M C] Forced Air Furnace 0 Radiant Baseboard or Panel (Elec-) Pump <br /> E] Boiler ❑ Central AC (3 Other: OnA i:p <br /> B. PRQJXCTSINE YUIRM:ii� Nat.Gas L.P. Oil Elect. Solid Solar <br /> . AG' %SO <br /> Space Heating El El 11 0 is El <br /> WaterHeating tU01tu5. Je )4,( El El 0 El El El <br /> ...........❑..... <br /> . ...................... <br /> MOO, <br /> I I I 11,117 111 <br /> 0 Site Constructed [0 Concrete ❑ Masonry E] Treated Wood <br /> E] Manufactured ❑ Other: <br /> .. ........ <br /> 6. <br /> . .. ....... <br /> Z.� <br /> T AREA ?.i ESTIMATED PRIf3JET -SIN <br /> F... <br /> Living area = 00 S uare Feet $ 50(vo. 00 <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 ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. Irealize <br /> the issuance of this/"permit44,tyff does not relieve me of compliance with other applicable� codes and ordinances. <br /> I <br /> Applicant lg n a t u r e Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> Town E] Village <br /> El City Of: <br /> IMUNICIPMMU ABEitt <br /> # Z - -Lao /J lz2 <br /> PERM11T,1$$Uf <br /> SBD-8254(N 09/89) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />