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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 /> �Y- — v L <br /> Street Address L c n j 120 Boy -4-q5- Go s"w T w <br /> 577LOf <br /> City State Zip Code Telephone No. (Include area code) <br /> ( ff-634 -/6 3 <br /> PIaOr>C,O1vATI© <br /> Building Addressff Subdivision Name Lot# Block# <br /> Nt V Ol Cjqgo c4. CS M Vf" <br /> Legal Description IJ Parcel No. <br /> 1/4, 1/4, Section s5 T N, R j E or W <br /> I <br /> OJECT, <br /> TYPE .P9ROINC711VA.0 E TTIPMENT <br /> ® 1 Family I,$ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ID Boiler ® Central AC ❑ Other: <br /> PROSECT ENERGY SOURCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ® ❑ ❑ ❑ ❑ <br /> Water HeA ' ❑ ® ❑ ❑ ❑ ❑ <br /> 4. PRIIJECT CJNSTRTTCTION TYPE a: PRUJECT FOUNDATION <br /> ® Site Constructed 19 Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other e.c <br /> PR!AJECT AREA ? ESTI ITER PR03ECT BVILI}Il�TG COST <br /> Living area= 1000 Square Feet 1 $ ¢$r 0Q 0 <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 CommALHR 20-25, still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> kms. " Imo' i2 A 4-a-- / 3- 117 <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY EFOREFORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUJN JURISDICTION Town ❑Village ❑ City ❑ County of: - <br /> NIAL NIIBERt <br /> a£l�vaatHng.l [ar► —�- <br /> PERlVII'lr 1<,SSUEI B3t': IaATE <br /> c� C / r IS 'IIED T-CJ q9 <br /> SBD-8254 (R08/97) White-Issuing Jurisdiction Pink-State Nkiltin 3#Days Yellow-Applicant <br />