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Submit to non-enforcingWISCONSIN 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 YELLOW COPY. <br /> Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(m)] <br /> Last Name First Name Middle Initial <br /> lr U i <br /> Street Address <br /> 0 3 � <br /> In' State Zip Code Telephone No. (Include area code) <br /> SJ_ Irl lrs �Sa .3 3 / X37 - i 3 S— <br /> {/ry S <br /> 777777777 <br /> Building Address Subdivision Name Lot# Block# <br /> d 3 as Gq 6r c1 s�K Lk R� G�., s r d L lie Ou h1� <br /> csrtiu: p,aaa- <br /> Legal Description Parcel No. <br /> W 1/4, 1/4, Section 3 T N, R ? E or W <br /> EQUIEl <br /> 1 Family Forced Air Furnace 013adiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Family 11Boiler 0--Central AC ❑ Other: <br /> 3;EN1GNat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4. CONSTRUCTION TYPE &FOUNDATION <br /> ❑ /Site Constructed ncrete IT-Masonry ❑ Treated Wood <br /> Manufactured ❑ Other(specify): <br /> 6.AREA 7. ',ESTIMATED BUILDING CAST <br /> Living area= Square Feet $ — <br /> I vouch that all the above information is correct,and understand that the issuance of this permit is for administrative purposes only. <br /> I understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Comm/ILHR 20-25,still applies to all new I-and 2-family dwellings and must be complied with. I understand that the <br /> issuance,"s permit does not relieve me of compliance with other applicable codes and ordinances. <br /> A plicant's Signatur Date Signed <br /> MUST BE COMPLETED BY THE MUNICIPALITYBEFORE FORWARDING PINK PLY TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> IS JURISIIIC `LUN, Town ❑ Village ❑ City ❑ County of: <br /> MUNICIPALITY- ER: FE::E S: .� <br /> of Dwelling Location <br /> PERMIT ISSUED BY: DATE <br /> SBD-8254 (R.2i98) White-Issuing Jurisdiction Pink-State Within 30 Days Yellow-Applicant <br />