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submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings <br /> and 2-family dwellings (mss. Stats. 101.63 (7) & 101.65 (3)) Division <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 /> PERMIT<APPLICANT <br /> Last Name First Name Middle Initial <br /> Street Address \ <br /> V- <br /> city State Zip Code Telephone No. (Include area code) <br /> PltOr CT LOCATION <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parcel No. <br /> �] 1/4, 1/4, Section T N, R _E or' <br /> 1.<PROJECT TYPE .PROJECT W C E TIIPMENT <br /> 'A 1 Family OL Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 F2mi1 ❑ Boiler ❑ Central AC ❑ ,Other: <br /> 3., PROJECT E1ERGYiSU7(1RiE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> Water H ' ❑ ❑ ❑ ❑ ❑ <br /> �#. PROJECT CCENSTRTTCTICIN T 'P 5.: PROJECT F ..... I#)N <br /> Site Constructed ❑ Concrete ❑ Masonry Treated Wood <br /> ❑ Manufactured ❑ Other(spec : <br /> d. PROJECT AREA 7. ESTAlIATE)4?PROJE��CT BIIII.,AING COST <br /> Liviniz area= 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/IL.HR 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 /> 8 /0/CC,,P <br /> licant's Sia Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> SUINGJTJRI DICTIbN: Town ❑Village ❑ City ❑County of c llf J2 lL <br /> PERMITS, ED... �1 IRATE <br /> SBD-8254 (R O&97) White-Issuing Jurisdiction Pink-State Viithin 30 Days. Yellow-Applicant <br />