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Wissonsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. See instructions on back of yellow copy. <br /> P,ERk11Ifi AIp PLIANTN <br /> Last Name First Name Middle Initial <br /> -r/4Yeo d <br /> Street Address <br /> /J_� <br /> - OY/ <br /> City ' te Zip Code Telephone No.(include area code) <br /> WA 6 <br /> .......... <br /> Building Address Subdivision Name Lot# Block # <br /> L� <br /> s ACJ � I <br /> Legal Description I Parcel No. <br /> 1/4, 114, Section 3S T 4 llL N, R E oi�W <br /> MRO. 1Y <br /> .. . .. ... <br /> 1 Family Forced Air Furnace E] Radiant Baseboard or Panel Elec.) E] Heat Pump <br /> 2 Family E] Boiler E] Central AC 0 Other: <br /> PRO CT1ENtRGYSL_ <br /> ­ Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 11 0 11 F-1 0 Cl <br /> Water HeatinEl 10 0 El El El <br /> CAR. <br /> IWO 2..NZ <br /> 4.9" 0 <br /> Site Constructed Concrete ❑ Masonry F] Treated Wood <br /> E] Manufactured F1 Other: <br /> 6. MAREA 7. 1 T!MATEDPRt3iECtBUlLDING 05T, <br /> Living area = 5 uare feet -o , t-,d--v <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 permit does not relieve me of compliance with other applicable codes and ordinances. <br /> 4ZZAe M/ 2Q4�_ J= J— <br /> .pplicant's Signature I (�'r Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUIR-6 JURISDICTION, <br /> own 0 Village ❑ City of: <br /> A— <br /> :MUNICIPALITYNU <br /> # <br /> PERMIT <br /> AS9 _or)\ DATE <br /> SBD 8254 IN 09/89) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />