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. "g, <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin PS'S— <br /> municipalities for new l- PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) <br /> SEE INSTRUCTIONS ON BACK OF SECOND FLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last Name First Name Middle Initial <br /> Street Address <br /> C' State Zip Code Telephone No. (Include area code) <br /> "J""e-vV ztv 71S 2517 Oe`z <br /> Building Address Subdivision Name Lot# Block# <br /> CQ3'3(pao /jeatA 1 '3 1 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R EorW <br /> C] I Family <br /> 0 Forced Air Furnace MP <br /> 2 FaZlBoiler 0 Central AC 0 Other: <br /> Nat. Gas L.P. 10jill Elect. Solid Solar <br /> Space Heating 0 0 0 <br /> Water Heating 0 0 0 <br /> eff, M <br /> Site Constructed 0 Concrete )X Masonry 0 Treated Wood <br /> 0 Manufactured(to the WI UDC;not U.S. HUD code) 0 Other(speci <br /> 1101 Rlffll" <br /> & <br /> Living area Square Feet <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm 20-25,still applies to allnew I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this per t d not roeve me of compliance with other applicable codes and ordinances. <br /> AVplicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIP I BEFORE FORWARDING PLY 2 TO THE STATE DIVISION PF SAFETY AND BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> SBD-8254 (R.2/00) Distribution:0 Ply I-Issuing Jurisdiction OPly 2-Municipality Forwards to State If New Dwelling OPly3-Applicant <br /> ISSUING JURISDICTION <br />