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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new l- PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings (Wis. Slats. 101.63 (7) & 101.65 (3)) <br /> SEE INSTRUCTIONS ON BACK OF SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> .......... 'a <br /> 0011 <br /> Last Name First Name Middle Initial <br /> AmD G R60 J AE_ <br /> Street Address <br /> E5r7q Er- 2t Ave. 5, <br /> City State Zip Code TLIZ)— <br /> phone No. (Include area code) <br /> L-S tyli 6 Sq 7,Z <br /> ..................... <br /> Building Address Subdivision Name Lot# 431m-k-* <br /> Legal Description [[ Parcel NO. <br /> 1/4, —1/4, Section 3 T ON, R E or 6c;o _ — &_ <br /> _ a — <br /> Jc/ <br /> 4 101 re <br /> 1 11 11'0411 <br /> I Family Forced Air Furnace 9#1kadiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Familz 0 Boiler -N,-'C'entral AC 0 Other: <br /> Oil Elect. Solid Solar <br /> 0 ❑ 0 0 <br /> 0 <br /> F 1 IN, <br /> Site Constructed Concrete 0 Masonry 0 Treated Wood <br /> 0 Manufactured to the WI UDC; not U.S. HUD code) 0 Other(sgecify): <br /> kB <br /> M <br /> NOR <br /> j ST- /000 80lseRT (.cv <br /> Living area= c2 0 0 Square Feet $ 0'2c2 0 ) 000 ' <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 co pliance with other applicable codes and ordinances. <br /> 11A X00 Z' <br /> Alic'ant_'s Si nature Date SignecV <br /> MUST BE COMPLETED BY THE MUNICIPAL BEFORE FORWARDING PLY 2 TO THE STATE DIVISIqN OF SAFETY AND BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> # 0 �7 j,_ <br /> SBD-8254 (R.2/00) Distribution:OPly I-Issuing Jurisdiction OPly 2-Municipality Forwards to State If New Dwelling OPly3-Applicant <br /> ISSUING JURISDICTION <br />