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WisconsinJJepartment of Industry, WISCONSIN ADMINISTRATIVE I' n Tn <br /> Labor and Human Relations �( <br /> BUILDING PERMIT APPLICATION <br /> (Wis.Stats. 101.63(7)& 101.65(3)) <br /> Submit to non-enforcing municipalities for newt-and 2-family dwellings. MAY 3 1998 �. <br /> SEE INSTRUCTIONS ON BACK OF YELLOW COPY. '3URNE <br /> The information you provide may be used by other government agency programs[Privacy Law,s. 15.04(1)(m)1. T�COON <br /> RIIIi#i.APPU�CANT <br /> Last Name First Name Middle Initial <br /> Street Address <br /> CD <br /> City State Zip Code Telephone No.(include area code) <br /> I'" C1JIIr I'LOGAINxx <br /> Building Address Subdivision Name Lot# Block# <br /> <a>1.�ell VtoIlerkD c 5 M 1 (ip (D Ise 1 <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section 2J ,T N, R_ E or <br /> '! PROJECT TYPE 2.. IPROJIrCT HVAC EQUIFMI"NT <br /> 1 Family09 Forced Air Furnace ❑ Radiant Baseboard or Panel (Elec.) ❑ Heat Pump <br /> ❑ 2 Family ❑ Boiler ❑ Central AC ❑ Other: <br /> 3.f:PROJECT ENE:Rf,Y SOURCE €II Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ 16- ❑ ❑ ❑ ❑ <br /> Water Heating ❑ ❑ ❑ ❑ ❑ <br /> 4> PR011wCT C©WSTRUCTI£ N I YPI± 5. P (EJII«C I"0 NIDA 1©�1 <br /> ❑ Site Constructed RIConcrete ❑ Masonry )[Treated Wood <br /> Manufactured ❑ Other(specify): <br /> 6. PROJEC f ARf"A T. ES fiMATED PRIDIECT.013 DIN+G:C05T <br /> } 00 + <br /> Livin areB '3 Square Feet $ OZDO <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 1-and 2-family dwellings and must be complied with. I realize <br /> the issuance of this permit does not relieve me of compliance with other applicable codes and ordinances. <br /> Applicant's Signature Date 9g1fied <br /> MUST BE COMPLETED BEFORE SUBMITTING TO DILHR: <br /> IS SUI N6LJURISDICTION Town ❑ Village ❑ City ❑ County of: <br /> C) Where Dwelling <br /> MUNICIPALITY NUMBER: Located EEIES: 071 <br /> PERM#T IS5UED BY: �ufn2t �ru�c DATE Is51JED.', Gf-as-Cj� <br /> 5BDB 6254(R 09/94) White-Issuing Jurisdiction Pink-DILHR Within 30 Days Yellow-Applicant <br />