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21175 <br /> Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor and Human Relations <br /> BUILDING PERMIT APPLICATION <br /> (Wis.Slats. 101.63(7) & 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. <br /> SEEINSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide maybe used by other government agency programs[Privacy Law,s. 15-040)(m)]. <br /> ........................... <br /> ..... ..... ... ... ...... ................. ......... ........ <br /> ............................................. <br /> .......................... <br /> ..................... <br /> PERMff..APPLICANT <br /> . .. ... .. .. ......... .. ... ....... <br /> .. ................. ................. .............. <br /> ........ ...... . ... . ... ... ... ... <br /> Last Name First Name Middle Initial <br /> j '. rt —,7,L-J <br /> Street hddress <br /> nf7 96 19 X, Li,'.r <br /> City tt State Zip Code Telephone No.(include area code) <br /> _T#U 0 t y- Grolt <br /> .... ................ ... .. <br /> ............. ... <br /> RO ...... <br /> .......... <br /> ... ..... .. ....... .. ... ... .. ... ... ... ....... ........ ......... ............... <br /> ACT .. . . ........... <br /> ..................... <br /> Building Address Subdivision Name Lot# Block# <br /> PA A A_18 CSM V.12 P.90 6 <br /> Legal Description Parcel No. <br /> NE 1/4, SE 1/4, Section 6 T 40 N, R I(,W E or W 20-4306-01-210 <br /> ... .. ... ... . .. ..... ... ..-.....I ....... I................�......�7...7.77 .7" 7 .­7..... <br /> �:�.I 7777 .I <br /> .... <br /> .. <br /> ..M.010. -PE MVACE UIPMENT":�'::'..::: .V :.: X: <br /> . . ..CTJY <br /> 1 Family <br /> ..... .............. ............... <br /> Forced Air Furnace E] Radiant Baseboard orPanel El ec.) ❑ Heat Purnp <br /> E] 2 Family 1­1 Boiler t9 Central AC EJ Other: <br /> K....PROJECT E�NERGY SOURCE Nat. Gas L.P. Oil Elect- Solid Solar <br /> Space Heating El El 11 F-1 1:1 <br /> . Water Heating ] ED <br /> ... ... ..... . <br /> TY <br /> 4:..::�,::PROJ.ECTCONSTRUitTlOt4.� PE .":PROJECT FOUNt3ATION <br /> Site Constructed ❑ Concrete Masonry El Treated Wood <br /> El Manufactured E] Other(specify): <br /> ... ......... <br /> SU14DIN10.. OSTii!��i:�:. .. <br /> $,.:�iPROJECTAR.EA­ . ...... ......... <br /> . . . . .. .. ... . . . . . . . ........ <br /> ...... 9T, <br /> Living area 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. Slats. I understand the Uniform Dwelling <br /> Code, Chapters ILHR 20-25, still applies to all new I-and 2-family dwellings and must be complied with. I realize <br /> th ' uance of this rmit does not relieve me of compliance with other applicable codes and ordinances. <br /> ;irc WM, 0i -3— <br /> ­ <br /> Ap i nt'sSignat VTDate Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> 1ISSUNISJURISDICTIOW [I Town E] Village ❑ City ❑ County of: Oakland <br /> Whe e 9 <br /> MUNICIPALITY NUMBER, # o 7 - 0 2 0 Located Dwelling FEESA9: None <br /> PERMIT ISSUED BY: Burnett County Zoning x DATE ISSUED: 3/2/98 <br /> 9 <br /> SBDB 6254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />