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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin '? (oc)�I <br /> municipalities for new 1- PERNUT 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 PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> MW <br /> Last Name <br /> First Name Middle Initial <br /> C2rq_1'c.- o 'c t e C . <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> e6 t Vo) Nx(�L <br /> Building Address Subdivision Name Lot# Block# <br /> 2a� 11 <br /> l�1R GiS �jj1 <br /> Legal Description Parcel No. <br /> 1/4, Section T N, R E or W <br /> W\1 Family qkForced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil 0 Boiler ❑ Central AC ❑ Other: <br /> " Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑❑ 0 ❑ ❑ ❑ ❑ <br /> Water Heatin <br /> ❑ Site Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> anufactured(to the WI UDC; not U.S. HUD code ❑ Other(s ecif ): <br /> Living area= `76 -Square Fee $ 7 <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 all new 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit doessJ n�ot�relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Sia ed e <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> # <br /> SBD-8254 (R.2/00) Distribution: ❑Ply I-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />