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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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> PERMIT <br /> .41C' <br /> Last Name First Name Middle Initial <br /> V <br /> Street Address <br /> I A)5_421.3,? 055 <br /> City StateZip Code Telephone No. (Include area code) <br /> e- 0 Uj 1 5 5�/8?? ,3 65-- .5001 <br /> PAT 240 <br /> JX <br /> Building Address Subdivision Name Lot# Block <br /> Chl " 4 <br /> Legal Description FParcel No. <br /> F, 1/4, 1/4, Section T :�q N, R Eoro - <br /> _At I OA4 <br /> j <br /> W' _C,FQVI <br /> T -A <br /> C,T- <br /> 1. PROJE TYPE <br /> )& I Family )5-Forced Air Furnace 0 Radiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Family 0 Boiler 0 Central AC 0 Other: <br /> -k , <br /> 3.ENERGY"SOVRCE I Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 0 <br /> Water Heating 0 0 <br /> 4. CONSTRUCTION TYPE 5.FOUNDATION <br /> 4�Site Constructed 0 Concrete )EI-Masonry 0 Treated Wood <br /> 0 Manufactured 0 Other(specify): <br /> 6.AREA 7. ESTIMATED BUILDING COST <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. <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 I-and 2-family dwellings and must be complied with. I understand that the <br /> islanc,e of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> s <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISIQN OF SAFETY AND BUILDINGS <br /> ISSUING JURISDICTION, Town 0 Village 0 City 0 County of: <br /> MUNICIPALITY NUMBER: # 6 7 ,FEES: <br /> o€Dwelling Location <br /> PERMIT ISSUED'Illy: Atig, <br /> &N't S,U E <br /> SBD-8254 (R.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />