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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. 15.04(1)(m)l. <br /> CA ............... <br /> rh►150� <br /> ame <br /> First Name Middle Initial <br /> l <br /> Street Address <br /> vIf 0 U 6 /J0 l4k <br /> State ZipCode Telephone No (include area code) <br /> City <br /> 142, 77-777777777= <br /> C- 777777777777777=.. <br /> ............. <br /> ................. <br /> ............. <br /> q............... <br /> . ....... . <br /> L <br /> Building Address Subdivision Name Lot# Block# <br /> P76 Parcel No <br /> Legal-'55—escription 114, 1/4, Section T N, R E or W <br /> PR.O <br /> VACIQUIPME.. <br /> J <br /> X Baseboard or <br /> 1 FamilyForced iFurnace Radiant (Elec.) Heat Pump <br /> n 2 Family Boiler E] Central AC E] Other: <br /> JE Oil Elect- Solid Solar <br /> ENERGY SOURCE.�:� Nat. Gas L.P. <br /> 0 CT�E <br /> J ., <br /> Space Heating ❑ El El ❑ El <br /> Water Heating ❑ 'El El <br /> T'l.7,7.7,7777777777777777!'"' <br /> V "NST N: <br /> R <br /> Site Constructed Concrete E] Masonry ❑ Treated WOOCI <br /> fj Manufactured Other(specify): <br /> PROTECTA <br /> 0, <br /> At <br /> D PRQAE <br /> 7. ESTIMAT <br /> A <br /> lRE <br /> Livinq area = J Square Feet $ 46,060 <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 appliestoall new 1- and 2-family dwellings and must be complied with. I realize <br /> of this p <br /> the Lisance permit does not relieve me of compliance with other applicable codes and ordinances. <br /> iL <br /> Date gig necV <br /> LA licant's Signature <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> SSUING JURISDICTION. Town ❑ Village El City El County of: 6uj)!Sis <br /> I <br /> Where Dwelling <br /> Located TEES.,' Mme-) <br /> MUNICIPALITY NUMBER. # <br /> ISSUE©.'V] <br /> PERMIT ISSUDATEiiOEOIED BY: �,r,8,be <br /> SBt)B 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant 4X <br />