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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin 7R5­A_ <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 SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last Name First Name Middle Initial <br /> ,jI 5 ��slif,i X. <br /> Street Address <br /> O277Y 7/ Sfree� <br /> City State Zip Code Telephone No. (Include area code) <br /> lce CA ���" �a � <br /> o 9 - <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description / Parcel No. <br /> /ISG <br /> 1/4, 1/4, Section T N, R E o62 <br /> 1 Family El Forced Air Furnace ❑ Ra�diant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler C -Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> Water Heatin ❑ ❑ ❑ 9311 ❑ ❑ <br /> �„ „i?„ t sir t y�0/„i`�. G. �h..a"�c.",_ ' El' <br /> Site Constructed Er Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured to the WI UDC;not U.S. HUD code) ❑ Other(s ecif ): <br /> r�o0, ''.t Po '” r r...c t �� \z .:✓. ..., '' ��r "�} 1 �G.rT!! �� <br /> ,.. ..�.:./'.. <br /> Livingarea= Iip 3 cJ Square Feet 1013 sr $ /�e-t�q <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 1-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit does not relieve M&&ompliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY SEFORE FORWARDING PLY 2 TO THE STATE DIVISI N OF SAFETY AND ggLDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> rr <br /> low <br /> MH <br /> SBD-8254 (R.2/00) Distribution: ❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />