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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING ate of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION U uildings <br /> and 2-family dwellings Vis. Stats. 101.63 (7) & 1b1.65 (3)) ; <br /> SEE INSTRUCTIONS ON BACK OF YELLOW Y. JI/( f' <br /> Personal information you provide may be used for secondary purposes. [Privacjq gyve 5.04(1QI ft8 <br /> PERMIT APPLICANT` <br /> ............ <br /> Last Name First N Middle Initial <br /> �aC �. <br /> Street Address D Laye,,, <br /> City State Zip Code Telephone No. (Include area code) <br /> Lt1i' ,�az�' �1S-x417-s/oo <br /> PROJECT LOCATIONI <br /> Building Address <br /> � / /J Szu-bdi ' ion Name 1 /� /• Lot,# Block# <br /> �l..J� f�lf7'/S /YDI/[ ~! ii'S /QaQ/ e» /0 f3uYs �T <br /> e es.• <br /> Legal Description Parcel No. <br /> 1/4, .TF1/4, Section T 4 R /� E or <br /> 1. PROJECT TYPE 2.I'RO,IE�CT HVAC E ITIPMENT <br /> 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 FamilyAr Boiler ❑ Central AC ❑ Other: <br /> J PRO,�i CT NER,� 09.R��j, Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> Water Hea ' ❑ ❑ ❑ P� ❑ ❑ <br /> �R 'ROJECT CCINSTRUCTI�CI!N TYPE ' PRO, ECT FC1UNDA ON <br /> Site Constructed in ❑ Concrete Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other ec <br /> bR PROJECT A1A / 7 ESTIMATEIf PROJECT BUILDING COST <br /> Living area= Q 3 (� Square Feet $ P2 Oo <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/ILBR 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 d not reli me of compliance with other applicable codes and ordinances. <br /> �/QA,e <br /> A icant's Signature Date Si ed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTIr1N: Town ❑Village ❑ City ❑ County of S S <br /> 1IIJNIC` 'AI,I Y 111E # o Z - <br /> PTRMIT ISSUEI>SY: HATE / <br /> ................ <br /> uVl2L �f2 <br /> U.S <br /> SBD-8254 (R os/9'n White-Issuing Jurisdiction Pink-State W in 30 Days Yellow-Applicant <br />