Laserfiche WebLink
Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings Divisio -� <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 /> 4ryf mew`. •�.. r. <br /> Last Name First Name Middle Initial <br /> EK <br /> Street Address <br /> -3 0-1 <br /> City State Zip Code Telephone No. (Include area code) <br /> Ao\ a t5 - (053 -3va-1 <br /> Building Address Subdivision Name Lot# Block# <br /> 3137 as \0/ 1'13 <br /> Legal Description ^ Parcel No. <br /> 1/4, 1/4, Section a 3 T �� N, R I E o W <br /> ¢Cp`6uC,''.KCM�K"yE e�m^rA w' a d y`p �T ., y��?�K <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 ❑ x ❑ ❑ X ❑ <br /> Water Heatin ❑ ❑ ❑ ❑ ❑ <br /> ' ' �• REt Ks< t it3«;v.,a � wx@`«..ae hge• ,+y;3 n2m�\��-- n ,im'; <br /> ❑ Site Constructed 19 Concrete ❑ Masonry ❑ Treated Wood <br /> Manufactured(to the WI UDC; not U.S. HUD code) ❑ Other(s ecif ): <br /> x e r /a•a� ,.\ 4 3b m i sai <br /> Livin area= O' Square Feet $ a.� 000 <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 me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALIU PEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> ## �- <br /> �� r <br /> L11 I <br /> SBD-8254 (R.2/00) Distribution:❑Ply I-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />