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Moog <br /> Wisconsin 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[Privacy Law,s. 15.04(1)(m)1. <br /> PERMIT APPLif*ANT <br /> Last Name First Name Middle Initial <br /> Street Address <br /> N r73oef Co, <br /> City State Zip Code Telephone No.(include area code) <br /> Y <br /> e,V- ) 5 (,ill 5 7/5 , 495- 797V <br /> PaJ1~Cr N <br /> Building Address Subdivision Name Lot# Block # <br /> &SpS RJ <br /> �Jgal Desc//ription//dAdLQ Parcel No. <br /> 1/4, Sectiony\ T �J N, R E r W � � <br /> T.i PROJECT TYPE 2. 'PR 3JECT HVAC EQUIP: :ENT, <br /> 1 Family XForcedAir Furnace ❑ Radiant Baseboard or Panel (Elec.) ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler Central AC ❑ Other: <br /> .3.::.:PROJI«CT ENEiRGYSOURCE [vat.Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> 4 P CT CONSTRUCTION TYPE 5. Pt0J.ECT FOUNDATION <br /> ER'Site Constructed ❑ Concrete ❑Masonry Treated Wood <br /> ❑ Manufactured ❑ Other(specify): <br /> 6 .PROJECT ARBA 7. ESTIMATED PROJECT BUILDING COST is <br /> Living area 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 applies to all new i-and 2-family dwellings and must be complied with. I realize <br /> the issuance of this not relieve me of compliance with other applicable codes and ordinances. <br /> ' b 2 <br /> Applicant's Signat re Date Si ned <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> ISSUING JURISDICTIONt Town ❑ Village ❑ City ❑ County of: � <br /> MUNICIPALITY NUMBER.NUMBER. Where Dwelling- 0 Located FEES: <br /> PERMIT ISSUED BY: � ATE ISUD.'C0. � 6 9 <br /> 5BDB 8254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br /> n�a�m <br />