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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin =itfc ??qV6 <br /> municipalities for new I- 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 /> Last Name First Name Middle Initial <br /> ff)e mka <br /> Street Address <br /> 33 <br /> City State Zip Code Telephone No. (Include area code) <br /> wz 5�O 1 Q <br /> .t <br /> Building Address Subdivision Name Lot# Block# <br /> loWp 1.1 L , PslE P/jE-S I ,+ <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R E or W <br /> 11 IR, <br /> \„ <br /> 75 <br /> * B <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Famil ❑ Boiler 0 Central AC ❑ Other: <br /> „ <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> y��Pim <br /> w\?Yite Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC, not U.S.HUD code) ❑ Other(s ectf ) <br /> ,. � s r `t' r \ ..• K n:. <br /> Living 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. 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 com fiance with other applicable codes and ordinances. <br /> 2f-03 <br /> Applicant's§ignature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑Village ❑ City ❑ County of: � <br /> SBD-8254 (R.2100) Distribution: ❑Ply I-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />