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Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety and Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. See instructions on back of yellow copy. <br /> ....... ... .... ... ........."M <br /> PERIIITAPPIANT <br /> .. .. ... .. . <br /> .. ..... ... <br /> . .. ...... .......... <br /> ........... .... .. <br /> ........... . .... <br /> ......... . ......... .. <br /> ....... <br /> ............ <br /> ..... .. . <br /> ............_... ......... .. <br /> . ... ...... ... . .... ... <br /> ............... ........ ....... <br /> . ..................... ... . ... . ...... . .. ........ <br /> .. ... .. . ............ <br /> . ....... ............. .. .... .. .... <br /> ........... .... ... . .... ... .. <br /> . .... ....... <br /> Last Name First NameMiddle Initial <br /> jr-e Y e I & <br /> Street Address <br /> 60' 0 <br /> /T <br /> City state Zip Code Telephone No.(include area code) <br /> WHI' rC Pif4l If ki 16 / .2- A-1 T. I" f— J 9 <br /> ......... <br /> ....... <br /> '05 <br /> .. <br /> ......... <br /> .. ...... <br /> Build,nq Adj — , I Su <br /> , � , <br /> T6 w �7sp bdivision Name Lot# Block# <br /> k y t 4 x 4-,4 <br /> Leg <br /> 1/4, ,r— 1/4, Section? L/p T N� R M F w arcel No. <br /> ................ ... <br /> W'. <br /> X <br /> �X <br /> Ld'7. PROJECT TYPE PRQtEtY<RCt?UIPMEIvIf <br /> l Family <br /> Iff Forced Air furnace LJ Radiant Baseboard or Panel(Elec.) LJ Heat Pump <br /> E] 2 F E] Boiler C] Central AC 0 Other: <br /> ECT <br /> Nat. Gas L.P. Oil Elect. Solid <br /> Solar <br /> Space Heating El 0 El 0 <br /> Water I Heat'ng 171 El <br /> Ic <br /> ❑ Site Constructed ❑ Concrete 0?'Masonry C] Treated Wood <br /> oWanufactured El Other: <br /> ........... ...... <br /> : <br /> OJ EA 7. ESTIMATDPRgJE £81J11131NGCOST <br /> ........ <br /> X'x <br /> Living area = X0 Square Feet G e, 0 <br /> I present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101.65, Wis. Stats- I understand the Uniform Dwelling <br /> Code,Chapters ILHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. Irealize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's�Sgnalure Date Signed <br /> MUSTBE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> .......... <br /> ISS#JI <br /> I*4 SJORISMICTION E] Town E] Village ❑ City of: <br /> 2-i <br /> MIUNICIPAILITYNIU 015.1410 # <br /> PERMITISSU 0 By: <br /> DATUS <br /> 70 <br /> SBD 8254(N 09/89) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />