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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 /> E s <br /> § „ F a f �N <br /> Last Name First Name Middle Initial <br /> Street Address / <br /> City State Zip Code Telephone No. (Include area code) <br /> r x �4 4 <br /> Nnsk.,t.""E p a x <br /> Building Address Subdivision Name Lot# Block# <br /> P� /=o R <br /> Legal Description P cel o. <br /> _:�,9' 1/4, !� ,E 1/4, Section 1,7 _T P N, R E or W <br /> 1 Family Z1 Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> � .7Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ 14 ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ 0 ❑ ❑ <br /> ❑ Site Constructed J11 Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> G:AREA 7, lE'SATED BUII. T1G C' ST <br /> Living area za Square Feet $ ? <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 I-and 2-family dwellings and must be complied with. I understand that the <br /> issuance oft is permit does not relieve me of compliance with other applicable codes and ordinances. <br /> y _a ` oI <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALrrY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY ND BUILDINGS <br /> JO %C Town ❑ Village ❑ City ❑ Countyo£ <br /> MUNICIPALITY NUMBER: # - :�� <br /> ofDwelling Location <br /> PERMIT YSSUED BY• - <br /> DA <br /> SBD-8254 (R.2/98) --> <br /> White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br /> E� <br />