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Submit to non-enforcing WISCONSIN 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 SECOND FLY <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 /> Street Address <br /> X 11 <br /> City State Zip Code Telephone No. (Include area code) <br /> FVT <br /> f� <br /> Building Address Subdivision Name Lot# Block# \ <br /> Legal Description Parcel No. <br /> 1/4, 1/4, Section T N, R E or W <br /> ffW <br /> 1 Family ❑ Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump <br /> ❑ 2 Familz ❑ Boiler ❑ Central AC ❑ Other: <br /> Nat. Gas L.P. Oil Elect. Solid Solar <br /> Space Heating ❑ B ❑ ❑ FJ'� <br /> Water Heating ❑ L� ❑ ❑ 0 L<3 <br /> r'� r. fi�.• a.' f,a���� tri,:'. <br /> 19eSite Constructed Concrete ❑ Masonry ❑ Treated Wood <br /> ❑ Manufactured(to the WI UDC; not U.S. HUD code) ❑ Other(s ecif ): <br /> "`` t+r",''t $ +ii•' b Z „yy *x'�ph�P;5,',r#f!�ry+A O <br /> +4"+, i71 <br /> 'COST 'a,� hc\• 'fi< <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. I <br /> understand that onsite construction inspections will not be performed by the municipality,but that the Uniform Dwelling Code, <br /> Chapters Covim 20-25,sti plies to all new I-and 2-family dwellings and must be complied with. I understand that the issuance of <br /> this per s ve a of mp ' e with other applicable codes and ordinances. <br /> Applic is Si at a Da a Signed <br /> STB LETED BY THE MUNICIPALITY BEFORE FORWARDING PLY 2 TO THE STATE DIVISION OF SAFETY AND BUILDINGS <br /> Town ❑ Village ❑ City ❑ County of: <br /> 6�4 <br /> E07-6-3 <br /> SBD-8254 (R.2/00) Distribution: ❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Applicant <br /> ISSUING JURISDICTION <br />