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=hLdq a/ <br /> 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 /> = --- <br /> 3ji, <br /> i <br /> Last Name First Name Middle Initial <br /> Street Address <br /> City State Zip Code Telephone No.(Include area code) <br /> �a` .�a�'�?a .,M .h cf &a 7^'at(�SiV. fIDsrt ars " <br /> a _ �.yr 4W <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section �� T N, R E or Q., L)Lf v;- —0 <br /> �i <br /> 0s.� <br /> i. , <br /> " .i. <br /> ` " a . <br /> I Family Forced Air Furnace ❑ Radiant Baseboard or Panel E3 Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> ERY, O Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ �� ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ �/ ❑ ❑ <br /> 4 C S,IRVC OfltTl '�� ` .'FO � �� AT- ION <br /> " <br /> e , . <br /> a � <br /> Site Constructed ❑ Concrete Masonry ❑ Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6. <br /> AREA 7a 1TED;'II1T1'1'sTI�CAST <br /> Living area= Square Feet $ 0:,>i=—> <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 it does not relieve me of compliance with other applicable codes and ordinances. <br /> it <br /> Applicant's Sign tore Date Si ned <br /> MUST BE COMPLETED Y THE MUNICIPA kTYIBEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> ISSUING Town ❑ Village ❑ City ❑ County of: <br /> MUNICIPALITY NUMBER: # __;7_ - 3 ,gig; . ! <br /> of Dwelling Location <br /> PERMIT ISSUED.BY. DA' ,a <br /> Is� �w <br /> SBD-8254 (x.2/98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />