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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsil�v'-t6qq/ <br /> municipalities for new l- 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 PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last 7Ne First Name Middle Initial <br /> Street Address <br /> 672- A-ale /Z-e� K A <br /> City State Zip Code Telephone No. (Include area cod6) <br /> (v S- 761 79 <br /> Building Address Subdivision Name C_,51" Al Po?60 Lot# Block# <br /> 'I"we <br /> aci I:-z- 13 <br /> Legal DescriptionParcel No. 4N <br /> 1/4, 1/4, Section T N, R A/E ore <br /> mw <br /> .0 1 Family Forced Air Furnace 0 Radiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Famil 0 Boiler 21 Central AC 0 Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 9 0 0 0 0 <br /> Water Heatiu 0 0 0 jr 0 0 <br /> 7777t, <br /> 011 6,09" <br /> 19L Site Constructed Concrete 0 Masonry 0 Treated Wood <br /> , <br /> 0 Manufactured to the WI UDC; not U.S. HUD code) 0 Other(sRecifx): <br /> ( <br /> 50 <br /> Aw <br /> a WN&W <br /> Living area Square Feet $ 4:�0, 00�) <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 I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> t relf <br /> this permit M 'E eve me o compliance with other applicable codes and ordinances <br /> Appi-iTant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALIIX]BEFORE FORWARDING PLY 2 TO THE STATE DIVISIQN,OF SAFETY AND BUILDINGS <br /> 9 Town 0 Village 0 City 0 County of: <br /> /7T <br /> U <br /> SBD-8254 (R.2/00) Distribution: OPly I-Issuing Jurisdiction OPly 2-Municipality Forwards to State If New Dwelling OPly 3-Applicant <br /> ISSUING JURISDICTION <br />