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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 SECOND FLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> s: Y <br /> Last Name /First Name Middle Initial <br /> AV, 77 <br /> 7 <br /> Street Address <br /> /tea --r0 <br /> City State Zip Code Telephone No. (Include area code) <br /> o77' <br /> w syr a i lis= 6� /s"� <br /> k� <br /> ivision Name Lot# Block# <br /> Building Address Subd <br /> -:�, 7S- GGusvTyLiAj <br /> S P w2 " Sd <br /> Legal Description q Parcel No. <br /> NOE- !LF_1/4, SAS 1/4, Section . �T _�N, R�or W <br /> ,W <br /> 1 Family 19 Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ❑ Boiler ❑ Central AC ❑ Other: <br /> .r <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heatin ❑ ❑ ❑ ❑ ❑ <br /> ❑ Site Constructed 10 Concrete ❑ Masonry ❑ Treated Wood <br /> Manufactured to the WI UDC;not U.S. HUD code ❑ Other s ecif , <br /> �� <br /> Livin area= S uare Feet $ <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Si a Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALI EFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑Village ❑ City ❑ County of: C <br /> SBD-8254 (R.2/00) Distribution:❑Ply 1-issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />