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Submit to non-enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wiscons*iVV'?j7 <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 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 /> . 2LX jAlau-y'� <br /> Street Address <br /> 7 L) 2 <br /> D <br /> City j Siate Zip Code Telephone No. (Include area code) <br /> &A/ S"3 7S <br /> Building Address '0 Subdivision Name Lot# Block# <br /> IVZ�) Vz 07 <br /> -,Z <br /> Legal Descriptionar <br /> 1/4Section T 16 <br /> 1/4, _�&N, R cel No <br /> , E or <br /> aq "a <br /> Baseboard or Panel 0 Heat Pump <br /> 0 Other: <br /> Oil Elect. Solid Solar <br /> Space Heating 0 0 0 0 0 0 <br /> Water Heatin& 0 0 0 <br /> ' A <br /> 0' & Wide <br /> N7 <br /> Site Constructed Concrete 0 Masonry 0 Treated Wood <br /> ❑ Manufactured to the WI UDC; not U.S. HUD code) 0 Other(specify): <br /> '77777'7777777 777 , <br /> q M <br /> Living area= Z ®© Square Feet 5;"16, 0 <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 does not relieve n <br /> )e of compliance with other applicable codes and ordinances. <br /> XA <br /> Z0 0Z <br /> Uplicant's Signature J Date Si ed I <br /> MUST BE COMPLETED BY THE MUNICIPALIXY/BEFORE FORWARDING PLY 2 TO TM STATE DIVISION Of SAFETY AM BUILDINGS <br /> Town 0 Village 0 City 0 County of: <br /> SBD-8254 (R.2/00) <br /> Distribution: OPly I-Issuing Jurisdiction ElPly 2-Municipality ForwarL4ate If New welling OPly 3-Applicant <br /> ISSUING JURISDICTION <br />