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Wisconsin Department of Industry, WISCONSIN ADMINISTRATIVE S)fety and Buildings Division <br /> Labor and Human Relations BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for new 1-and 2-family dwellings. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. <br /> Last Name First Name Middle Initial <br /> Street Address <br /> I -IZZ A4Lu- t,& ew'Clc 6, <br /> City State Zip Code//// Telephone No (include area code) <br /> Z) / <br /> p '0 N /Z ,--7-8 <br /> ....... .... <br /> .................. <br /> ........... ... .. <br /> 1_11..... ..I. ......... <br /> PNi r .1.. <br /> Building Address Subdivision Name Lor # Block# <br /> -5 /4 A4 tL I <br /> Legal DescriptionParcel No. <br /> '_)1E 1/4, 1�0,J 1/41 Section 1;4—) N. R <br /> T I�E 4;7W) cp q—31 <br /> ............... ...... ....... <br /> HM �X <br /> 1 Family ❑ Forced Air Furnace Radiant Baseboard or Panel (Elec.) ❑ Heat Pump <br /> f-1 2 Family ❑ Boiler 1­1 Central AC ❑ Other: <br /> Nat-Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 11 El 1-1 El 11 11 <br /> Water Heating El El <br /> . ......... <br /> goacro-M <br /> J9 Site Constructed ❑ Concrete )0 Masonry C] Treated Wood <br /> C] Manufactured F'1 Other: <br /> ;::'­ .. .... : x,.......... <br /> Pit: <br /> 04 <br /> MATE INGVOST, <br /> g <br /> Living area Square Feet $ -7 S 0 ,00 <br /> I present that all the above information is correct, and understand that the issuance of this permit is for <br /> administrative purposes only. Onsite construction inspections will not and shall not be performed by the <br /> municipality which has not assumed jurisdiction per s. 101.65, Wis. Stats. I understanJ the Uniform Dwelling <br /> Code,Chapters ILHR 20-25,still applies to all new I-and 2-family dwellings and must be complied with. ] realize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> il Z �F <br /> s:- <br /> Appl#nt's Signat Date Signed <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ./s <br /> Town C] Village El City 0 County of: <br /> Where DweIhng' <br /> IMUNIC,11P, ITY # r_) (L Located <br /> PERMIffS 0 Y. Cp <br /> IS_VE <br /> SBD-8254(R_02/90) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Ye' ow-Applicant <br />