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S <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- 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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> � p <br /> Last Name First Name Middle Initial <br /> I t_1, t C-H 19-eN <br /> Street Address <br /> 7Z 7 g S <br /> City State Zip Code Telephone No.(Include area code) <br /> °��P�Ci� "��r� 'M'!�,'k«'�M"eeJ 4 9. ;ESI •a#.,Pn edit/ v�4.! # .-Ri F .kk� "Y.'�4iY eek$ ` k''Je a. 1 i:. <br /> Building Address yg Subdivision Name Lot# Block# <br /> 66_75- ff4rvEr �i4n►svey� W1, e� V �� P zs� <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T ' � R fep E or® <br /> �V�s 1`' rr ' = fr4:.�"�.!.kT +�' ��3 a `, "rte f, 012v? q <br /> d �$ 1 J r.w <br /> i 1 Family �4 Forced Air Furnace ❑ Radiant Baseboard or.Panel ❑ Heat Pump <br /> /❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 0 `k' a K <br /> .1 b Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> 4.CONSTRUON'TYPE 5. OUNbATION <br /> GpT <br /> Site Constructed ❑ Concrete ❑ Masonry Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6.AREA 7. ESTIMATED BUILI)�N 'COST 4L <br /> Living area= 7&0 Square Feet $ X71 d OU <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 Comm/ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance of thi ermit doe of r lie a of compliance with other applicable codes_4a ordinances. <br /> xj <br /> Applicant's Signattog, Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISI®N OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> YSSUING RISD CTIOl�� e. <br /> MUNICIPALITY NUMBER: # - FEES.J F <br /> of Dwelling Location <br /> PERMIT ISSUED BY: �� <br /> � <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />