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�77a, <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 /> �1 F <br /> Last Name First Name Middle Initial <br /> Street Address <br /> � " Z f <br /> Cit' State Zip Code Telephone No.(Include area code) <br /> t �� is l,�► .5417a 677777777 , <br /> Building Address Subdivision Name Lot# Block# <br /> Loy- 3 CSM V 1' iA Go i, Lo 4- 13ti CS nn V8 P <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section a 9 T Zim R E oU <br /> ti <br /> .�'. PRO'; CT TYPE �,IAG EQUI�'1�IE1�1T <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 3.ENEGY' QRCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ X ❑ ❑ <br /> 4. CONSTRUCTION TYPE 5 FOUNDATION <br /> 21 Site Constructed 1$( Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6.AREA 7 ESTIMATED BUILDING COST <br /> Living area= llz Square Feet I $ <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 this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applic s ign re Date Signed <br /> MUST BE CO PLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING�I91ON, wn ❑ Village ❑ City ❑ County of: <br /> To <br /> MUNICIPALITY NUMBER; # - 3 FEES: <br /> _ <br /> OfDwelling Location <br /> PERMIT ISSUED BY: DATE <br /> U 1�f7 f�'J�il ISS ? <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />