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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. See instructions on back of yellow copy. <br /> FERMI I IM <br /> AR <br /> Last Name First Name Middle Initial <br /> W, -i;- <br /> Street Address <br /> City State Zip Code Telephone No.(include area code) <br /> PRk <br /> .. ......... <br /> OR'. <br /> V <br /> Building Address Subdivision Name Lot# Block# <br /> Legal DescriptionParte No. <br /> 114, 1/4, Section T N, R E (r�W) G �7 - :S33'+(5 l— 100 <br /> ....... <br /> R <br /> 1 Family 0 Forced Air Furnace El Radiant Baseboard or Panel (Elec.) E] Heat Pump <br /> 2 Family r-1 Boiler E] Central AC C] Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 0 11 El El ❑ <br /> Water Heatin5 El 55 0 11 13 ❑ <br /> .... ... ....... <br /> CT, Cr <br /> El Site Constructed [S Concrete ❑ Masonry $1 Treated Wood <br /> ❑ Manufactured E] Other: <br /> 6. MEA U1 114GC05t <br /> Livino area = 162- 0 c-rjarp Feet 01 <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 /> , Chapters er; <br /> Cod Ch t s ILHR 20-25,still applies to all new 1- and 2-family dwellings and must be complied with. I realize <br /> the <br /> e sua ceo this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> o //- 3y— <,:3-0 <br /> Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> IS <br /> Town ❑ Village ❑ City of: <br /> MUKKIPAUTYNUFAIIIRt # co-t <br /> . ... ... ...... <br /> 0 <br /> 1 154" <br /> U�r 0 C <br /> SBD-8254(N 09/89) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />