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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 /> 7777777777-7,77,7- 7 <br /> Last Name First Name Middle Initial <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> bL-o, .e-5 Nle/ SSSo�S` &5-1- 76Z 'i�3 Sa <br /> t - , Q <br /> .t i� ,Y '"$%pial q 'r'b�-.: <br /> . . ^- <br /> Yv" w�, °. ro Lot# Block# <br /> Building Address Subdivision Name <br /> a63yG 6� w. s���,u, u� sY <br /> Lo Parcel No <br /> Legal Descnphon p ,.�`R <br /> 3� <br /> 1/4 1/4 Section S T N, _E or <br /> �yy Wr7 Ll p <br /> e 3A 'r`".a ffik3�a <br /> " <br /> 1 Family Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family Boiler ❑ Central AC ❑ Other: <br /> " ' Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ <br /> Water Heating ❑ ❑ ❑ <br /> 4•C(ITRUCTItN ;) Q31�IDATION <br /> NS <br /> Site Constructed � Concrete ❑ Masonry ❑ Treated Wood <br /> C Manufactured ❑ Other(specify) <br /> 6.AREA <br /> .. IlYIA E BV COST ry <br /> Living area= ``� )ro P Square Feet $ WO 000 <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/1LHR 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 does not refi ve a of compliance with other applicable codes and ordinances. <br /> I Z- DI <br /> Applicant's Sign re <br /> Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPAL Y BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ Countyof: <br /> ISSUINGRISD„ - <br /> MUNICIPAIITY <br /> gfDweling Locatirnp . <br /> -C� <br /> PERMIT ISUEI?"BY: x <br /> SBD-8254 (8.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />