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Wiscdhsin Department of Industry, WISCONSIN ADMINISTRATIVE Safety 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 /> The information you provide may be used by other government agency programs lPrivacy Law,s. 15.04(1)(m)]. <br /> PE :APP L <br /> Last Name <br /> First N me Middle Initial <br /> Z� 1:1,," Ili <br /> Street Address I F <br /> A 5,:6 2 <br /> City State Zip Code Telephone No.(include area code) <br /> 6141:71 <br /> Building Address Subdivision Name Lot# Block # <br /> 76 Z <br /> L z. /- JAW/Uzt��/ <br /> -egal Description <br /> Vn 1 , -S io rc lNo <br /> 114, 1/4, Sectn C T N, R E W n_:R C:� <br /> ' <br /> .PROJECT Ty Pe <br /> ZT -ENT' . ....... <br /> -X <br /> 471 1 Family Forced Air Furnace 0 Radiant Baseboard or—Panel(Elec.) ❑ Heat Pump <br /> 2 Family EJ Boiler E] Central AC E] Other: <br /> IE RGYSOURCE I Nat. Gas L.P. <br /> Oil Elect. Solid Solar <br /> Space Heating <br /> Water Heating ❑ El El <br /> W. <br /> 4 P116 'a .......... <br /> ItT N: <br /> 0.0ib <br /> 71FPUN <br /> Site Constructed E] Concrete ❑ Masonry Treated Wood <br /> Manufactured ❑ Other(specify): ;Ik <br /> XX <br /> i', ':.ROJECTARE E DI: <br /> A <br /> COS <br /> T <br /> Living area <br /> Square Feet <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 understand the Uniform Dwelling <br /> Code, Chapters ILHR 20-25,still a lr:'stcieall new 1-and 2-family dwellings and must be complied with. Irealize <br /> the issuan of this permit do ��ncp me of compliance with other applicable codes and ordinances. <br /> A pli t <br /> plicant'sSignature Date Sig <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> 777�� <br /> 1.S5U1NG:JURISD1"ON'. : Town El Village 0 City E] County of: <br /> C, <br /> MUNICIPALITY a <br /> NUMBER: Located fEE:Stl <br /> 04r A vo, _D Where Dwelling <br /> PERMIT ISSUED By RL1f-06j_L C —7 DATE:IS <br /> WE <br /> SLIDS 8254(13 09/94) White-issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />