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Subm to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wiscontp�yo � <br /> muni,--palities 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 /> M, <br /> S,I kits, <br /> Last Name First Name Middle Initial <br /> 7� <br /> Street Address <br /> �C[55-2_ &,wc>51E�u— <br /> City State Zip Code Telephone No. (Include area code) <br /> ftqok CIA 5S Lq 14 Ll oto -L4z -9�73 <br /> M lag MINIM= lk <br /> Building Address Subdivision Name Lot# Block# <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section 3Q T 4-C7 N, R kZ Eo <br /> 1B I Family 0 Forced Air Furnace 0 Radiant Baseboard or Panel 0 Heat Pump <br /> 0 2 Family 0 Boiler 0 Central AC 0 Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 0 11 0 0 0 <br /> Water Heatin 0 0 0 0 0 0 <br /> = <br /> RIMtri, yr. IN', NA Room,fim", M1011,I WON= <br /> .Site Constructed 0 Concrete 0 Masonry 0 Treated Wood <br /> 0 Manufactured(to the WI UDC; not U.S.HUD code) 0 Other(specl <br /> MEM <br /> Living area= L05D Square Feet $ A10 � (4*aAGS <br /> ,:;Nvj!�7Ll CN Ll <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 does not relieve me of compliance with other applicable codes and ordinances. <br /> �a\/ -ZOO Z-00 <br /> Applicant's Signature Date Riomp. <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town 0 Village 0 City 0 County of: 07 <br /> SBD-8254 (R.?JOO) Distribution: OPly I-Issuing Jurisdiction DPly 2-Municipag Forwards to State If New Dwelling OPly 3-Applicant <br /> ISSUING JURISDICTION <br />