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I 31&`7q <br /> Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin <br /> municipalities for new 1- PERMIT APPLICATION Safety and Buildings <br /> and 2- family dwellings (Wis. Stats. 101.63 (7)& 101.65 (3)) Division <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 /> ]PERMIr APPLICANT... <br /> Last Name First Name Middle Initial <br /> KE ) IY FAQL <br /> Street Address <br /> -7 3 3 5- ]Di c-7A;D WA Y <br /> City I State Zip Code Telephone No. (Include area code) <br /> _Tt4vek GAOve 46 !.-4.5 SS07 67 3?0 <br /> 777777777 <br /> Building Address Qe% io'-4 Subdivision Name Lot# Block# <br /> &/4N f4- C BA 5s LAX-6 5M 0 9_E5_ <br /> Legal Description Parcel No. <br /> — 1/4, — 1/4. section5 23 T _qO_N, R-17 E-,iv 107- o2-4o-z- 40-0 - 01 -0oino <br /> ... ............ ...... <br /> [ <br /> I :�TYPE .PROJECT_ T: R=CT RVAC Q NT <br /> 19 1 Family 9 Forced Air Furnace 11 Radiant Baseboard or Panel ❑ Heat Pump <br /> El 2 Ftp* El Boiler Central AC ❑ Other: <br /> VROACTENEIIGY pURCE Nat. Gas L.P. Oil Elect, Solid Solar <br /> Space Heating El N El 0 N El <br /> Water He'aft El El El 11 11 El <br /> PROJECT <br /> . . ... .. <br /> 01 <br /> CONSTRUCTION TW PROJECT FOUNDATION <br /> 50 Site Constructed 0 Concrete N Masonry El Treated wood <br /> 0 Manufactured 11 Other <br /> ...... .. .. <br /> &;,;PROJECT::AREA::...... 7 :ESTIMATED PROJECT BUILDING <br /> Living area= MOO Square Feet $ 60 ) 6 C' 0 <br /> 1 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 ComnV1LHR 20-25,still applies to all new 1-and 2-family dwellings and must be complied with. I understand that the <br /> irelieve me of compliance with other applicable codes and ordinances. <br /> 771 rx: —7 <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Village 0 City 0 County of <br /> ......... .... .......... .. Town..ISSUING:JURISDICTIONO�":.,:. .,::, <br /> . ... . ........ <br /> 7- <br /> SBD-8254 (R 08/97) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />