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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin '=)(0/6� <br /> municipalities for new I PERMIT APPLICATION Safety and Buildings Division <br /> and 2- family dwellings N5, StiltS. 10 1.63 (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 /> Last NameFirst Name Middle Initial <br /> 4 <br /> Street Address <br /> 13 CQ/C) .4-*vy <br /> 7eCity State Zip hone No. (Include area code) <br /> Building Address <br /> Subdivision Name Lot# Block# <br /> A 4-K9,D J94n)&jq)/&ASL-_- <br /> Legal Description <br /> City <br /> 41 <br /> S <br /> We 1/4, 1_*F_1/4, Section T :4:4LLC/ N, R 149 E or W Parcel No. <br /> I Family 0 Forced Air Furnace 11 Radiant Baseboard or Panel 0 Heat Pump <br /> 2 Famil Boiler 1% Central AC 0 Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating 0 ❑ 0 0 <br /> Water Heatin0 0r_I <br /> 0 0 <br /> ... ...... <br /> 14 <br /> !Fft <br /> Site Constructed <br /> Concrete ❑ Masonry <br /> Manufactured(to the WI UDC;not U.S. HUD code) 11 Treated Wood <br /> Livin area Square Feet al Is D C. ©C <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 es not relieve me of compliance with other applicable codes and ordinances. <br /> oca <br /> Applicant's Signature Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITY BEFORE FORWARD— <br /> G PLY 2 TO THE ATE DIVISION OF SAFETY AND BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> # <br /> L <br /> 1 /7 1- <br /> SBD-8254 (8.2/00) Distribution:OPIY I-issuing Jurisdiction OPly 2-Municipality Forwards to State If New Dwelling OPly3-Applicant <br /> ISSUING JURISDICTION <br />