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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin SI/5— <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 /> ° I <br /> l�lWft <br /> Last Name First Name Middle Initial <br /> ih,! /z 1 . <br /> Street Address <br /> City State Zip Code Telephone No. (Include area code) <br /> i' ✓ <br /> )_,,q KE � ��3 7a 9 - SL�7- 8570 <br /> �a. t �. <br /> ti. v� <br /> Q.��$t -`=',' a <br /> Building Address Subdivision Name Lot# Block# <br /> 7 I \ £J L,4t C OJ41C 110 /d <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T _!!71-ON, R E or W J <br /> lus' .„.�� <br /> F PRO S". E ,�� �`e'�i 'rdv 65 !''V, <br /> ;& 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> J.. Nat. Gas L.P. Oil Elect. Solid Solar <br /> 3.,BTEO �w� <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> CON°STRUC I OI�l' ' PE �5 +OUNDATION <br /> Site Constructed ❑ Concrete 15 Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> � AREA 7. ESI ATED BiTILIl►ING;COST r' <br /> Living area= 7 Square Feet 1 $ /`j QQ <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 1-and 2-family dwellings and must be complied with. I understand that the <br /> issuance of this permit does not reliev e of compliance with other applicable codes and ordinances. ' p� <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITYBEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> I Town ❑Village ❑ City ❑ County o£ <br /> NIUNICTPALITY r1UMBER• <br /> pfDwelling location <br /> PERMIT ISSUUD BY: <br /> • l <br /> SBD-8254 (x.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />