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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 (Wis. 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)J <br /> 7777 <br /> PERMIT APPLICANT <br /> Last Name First Name Middle Initial <br /> r 6 r <br /> Street Address <br /> o CvwH �� <br /> City State Zip Code Telephone No. (Include area code) <br /> PRO.IECT LOCATION <br /> Building AddressSubdivision Name Lot# Block# <br /> ©e'k 1 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T 9_N, R L E04 'SoL3 <br /> 1.' PROJECT TYPE 2. PtOJECT HVAC E Ul€PMENT <br /> 'S 1 Family El Forced Air Furnace ® Radiant Baseboard or Panel_ El Heat Pump <br /> ❑ 2 FaM#X ❑ Boiler ❑ Central AC ❑ Other: <br /> 3Ri PROJECT EIKERGY;SOURlCE Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ O ® ❑ ❑ <br /> Water HLatU ❑ $J ❑ ❑ <br /> 4R PROJECT CONSTRUCTION TYPE SR PROJECT F0111NDAT.ION <br /> ® Site Constructed ® Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other ed <br /> 6.' PROJECT AREA ?. ESTIATI3:A PROJEC'�'B[TII:DIN�GOSH` <br /> Living area= Square Feet $ p pv <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 t does no relieve me of compliance with other applicable codes and ordinances. <br /> ?_ '.-�L1' a-s9x <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MWWUNI BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING:JURISDICTION: Town ❑Village ❑ City ❑ County of <br /> 1ViIINICI4I.I'l€'Y7F <br /> NJM$ERt <br /> efu�x�fingLoeastat <br /> PERMIT[SSUEII BY: DATE �� <br /> SBD-8254 (R 08/97) White-Issuing Jurisdiction Pink-State With' 30 Days Yellow-Applicant <br />