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74-�7Caa'78 <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings <br /> and 2-family dwellings (Wis. Stats. 101.63 (7)& 101.65 (3)) Division <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 /> PERMIT APPLICANT: <br /> Last Name / First Name / Middle Initial <br /> Street Address <br /> Ye ar <br /> City I( State Zip Code Telephone No. (Include area code) <br /> 1'ROnCT LOI±ATI(�N <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 /> PROJECTTYPE .Ji~ROCT HVAC E UIPMENT <br /> ❑ 1 Family ff Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> PROSECT ENERG�' OUItCE 91 <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ is ❑ ❑ ❑ ❑ <br /> Water Hea ' ❑ ® ❑ ❑ ❑ ❑ <br /> 4: PROJECTCIfNSTI VCTION TYPE S« PRONM:":FOUNDATIE�N <br /> ,® Site Constructed Jig Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other Sc <br /> b PROJECT ASA 7 ESTIVIATEF PROJECT BLgIN:G COST <br /> Li ' area=1.2Uv 5 F SW=Fed $ 001 UUD <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 CHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance,of permit does not relieve me of compliance with other applicable codes and ordinances. <br /> licant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MNICIPBEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTION: Town ❑Village 11 City El County of: <br /> WNICIPxxx <br /> AI,IT <br /> PERMIT I55TTEII BY: F1 zHATE <br /> sBD-8zs4 ;Z7) White-Issuing Jurisdiction Pink-S to Within 30 Days Yellow-Applicant <br />