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C> � <br /> Wisconsin 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. <br /> SEEINSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide may be used by other government agency programs[Privacy Law,s. 115.04(1)(m)]. <br /> .......... <br /> I?ERMC <br /> ................... <br /> ............ ...... <br /> ................. .......... .... <br /> .............. <br /> T PPLICANT. <br /> .............. ......... ... .. <br /> ........... <br /> ............. <br /> Last Name First Name Middle Initial <br /> Street Aachress <br /> F12LI State Zip Code Telephone No.(include area code) <br /> .................. <br /> .......... <br /> X.. <br /> ............ ... .... <br /> .......... <br /> ........... % <br /> xIrOC .... ... Y. <br /> X.: Xxx <br /> .......... <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description 1/4 1/4, SectiSAPT N, R W E or Parcel No <br /> 0)—/QE <br /> on ) <br /> X, .......... ........ <br /> ............... <br /> v <br /> T idPROJECT HVAC:EQUIPMENT <br /> 1 Family :0 Forced XF Furnace El Radiant Baseboard or Panel (Elec.) E Heat Pump <br /> 2 Family F1 Boiler ❑ Central AC E] Other: <br /> PROJECT Nat.Gas L.P. Oil Elect. Solid Solar <br /> Space Heating El 1-1 El 1:1 El <br /> Water Heating E] El El El El <br /> .. ............. <br /> .......... <br /> RPRONSTRUCT ONWP <br /> S. PROJECT NDAT 0 ......... <br /> .... ...L <br /> Site Constructed J&Concrete E] Masonry ❑ Treated Wood <br /> E] Manufactured E] Other(specify): <br /> :X :x� ....... <br /> 6. <br /> ...PROJECT AREAXXX <br /> ESTIMATED....L.... <br /> PROJECT <br /> !00401N. <br /> � <br /> .......... <br /> L <br /> Living area = 142a 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. Stats. I understand the Uniform Dwelling <br /> Code, Cha ters ILHR 20- 5, ill applies to all new l-and 2-family dwellings and must be complied with. I realize <br /> the issua e of this pe it es not re eve me of compliance with other and ordinances. <br /> A <br /> li at <br /> Da Signe <br /> MUST BE COI!l6tEEBEFORE SUBMITTING TO DILHR: <br /> JURISDICTION Town ❑ Village E] City ❑ County of: <br /> Where Dwelhn <br /> ALIT g',­ <br /> :MUNICIP Y NUMBERO Located FEES: <br /> By. <br /> a r�� I <br /> PER ff ISSUED L 1 1. t LDATE:1S.. . C <br /> . :: i i1 - . <br /> M <br /> U <br /> _7 <br /> SBDB 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant AIN <br />