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Wisconsin Department of Industry, WISGONSIN 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 11-and 2-family dwellings. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> The information you provide may be used by other government agency programs[Privacy Law,s. 15.04(1)(m)]. <br /> ..... ....... ... <br /> II <br /> ........ ..... <br /> q <br /> !t M.ff A <br /> ... . P. 1 0.011.�7�::: ............... <br /> Last Name First Name Middle Initial <br /> 7z--_� <br /> Street Address <br /> 766 -11 / 3o -71/ <br /> City State Zip Code Telephone No.(include area code) <br /> Z_ IYU1 � 3 -5-3 377 <br /> X­ <br /> p <br /> . ........ ...... <br /> . ............. <br /> .. ...... ...... <br /> P <br /> _X: ....... ...... <br /> Building Address Subdivision Name Lot# Block# <br /> '50UT-// <br /> Legal Description Parce No. <br /> 1/4, 1/4, Section T O N, R_/7 E oll7y) —�o) <br /> ............ <br /> X: <br /> HVAC <br /> P <br /> PRO)I EQUI.-MENT�N ......... <br /> ,M 1 Family 9 Forced Air Furnace 0 Radiant Baseboard or Panel (Elec.) ❑ Heat Pump <br /> E] 2 Family n Boiler E] Central AC [_1 Other: <br /> :3 <br /> Xxx PROA,CTINIERGY SO IARCE [vat- Gas L.P. Oil Elect. Solid Solar <br /> Space Heating El El El ❑ ID <br /> Water Heating F-1 El ❑ <br /> .......... <br /> ............. <br /> C.::. RUJIECTC N T K"Of S. PR I ECT DAAON. <br /> ,0 S R .. ....0 <br /> JQ Site Constructed g Concrete Jg Masonry E] Treated Wood <br /> n Manufactured E] Other(specify): <br /> :i xxx <br /> G 0 s <br /> 46 KOKO: ,99A PROgC-51131 ON T <br /> ...... ......... <br /> xx:xx <br /> Living area $ Zo <br /> 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, 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 relieve me of compliance with other applicable codes and ordinances. <br /> Applio-nt'sSignatu rli Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISS01N10:),URI:tbl1dId;N., Town E] Village E] City E] County of: Un�n <br /> : x <br /> Where Dwelling... <br /> :MUNICIPALITY NUMBER. Located /0" <br /> PERMIT ISSUED BY' ZV101'lr., <br /> VAI <br /> SBD8 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant APT% <br />