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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 SECOND PLY <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> ........... <br /> Last Name First Name Middle initial <br /> 1-4701 '0 Y, <br /> Street AddresC) <br /> 'q'50�1 <br /> City State Zip Code Telephone No. (Include area code) <br /> 111QKeo-'11e__ <br /> 'p <br /> Building Address Af r� Subdivision Name Lot# Block# <br /> lcql �R loe— Aies rx-p—S Y <br /> Legal Description Parcel No <br /> 1/4, _ 1/4, Section _T N, R EorW 7L W <br /> ............. <br /> N NMI <br /> ;K 1 Family Forced Air Furnace 0 Radiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Famil 0 Boiler 0 Central AC 0 Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 -1;6 0 0 0 0 <br /> Water Heating 0 0 0 0 0 0 <br /> AM <br /> Site Constructed Concrete 0 Masonry 0 Treated Wood <br /> 0 Manufactured'�to the WI UDC;not U.S. HUD code) ❑ Other(specify) <br /> W 4 0 1 IV13 <br /> Living area Square Feet $ Zfo) 0(f;o <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 I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this permit d <br /> ,pe0ot relieve compliance with other applicable codes and ordinances. <br /> /Kpcant's Sig(nanture" Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITN BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> I L <br /> 161tk� <br /> / �jA <br /> SBD-8254 (R.2100) Distribution: OPly I-Issuing Jurisdiction 0PIy2-Municipality ForwarWState If New Dwelling DPly 3-A pplicant <br /> ISSUING JURISDICTION <br />