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Wisconsin Division of WISCONSIN UNIFORM BUILDING Application No. <br /> Safety and Buildings PERMIT APPLICATION /44 C ' <br /> Wisconsin Statutes 101.63, 101.73 The information you provide may be used by other government agency Parcel No. <br /> (Instructions on back of white ply) programs(Privacy Law,s. 15.04(1)(m) <br /> PERMIT REQUESTED ❑ Constr El HVAC ❑ Elec ❑ Plbg ❑ Erosion Other: <br /> Owner's Name Mailing,Address <br /> - Tel. <br /> 4<_J-.--.c--s.); E,f.,,,,_-_, FAX <br /> t-4 " C X4.1(1.4-=J -- a- '-3 -�i?, t <br /> I2II5. V(t`a4 FAX <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# Mailing Address-- Tel. <br /> J�/ (-rT at iZt CI: W 1 FAX <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# Mailing Address Tel. <br /> FAX <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# Mailing Address Tel. <br /> FAX <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# Mailing Address Tel. <br /> _ FAX <br /> PROJECT LOCATION Lot area <br /> Sq.ft. 1/4, 1/4 Section ,T N,R E(or)W <br /> Building Address____ Subdivision Name <br /> Lot No.54 Block No. <br /> t� '- t' {rztr VIi _-4 ='„ V( G_r l <br /> Zoning District(s) Zoning Permit Front Rear Left Right <br /> 1 No f7 - °' etbacks ft. ft. ft. ft. <br /> 1.PROJECT 3.OCCUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE , <br /> ❑New ❑Repair ingle Family Entrance Panel ❑Forced Air Fumace Fuel Nat LP Oil Elec Solid Solar <br /> ❑Alteration ❑Raze CJ Two Family Size: amp ❑Radiant Baseboard/Panel Gas * <br /> E3`Addition ❑Move ❑Garage Service: ❑Heat Pump Space Htg <br /> ❑Other(print): ❑Underground ❑Boiler Water Htg <br /> ❑Overhead ❑Central Air Conditioning '❑Dwelling unit will have 3 kilowatt or more installed <br /> ❑Other 4.CONST. 7.FOUNDATION ❑Other electric space heating equip.Infiltration control option is <br /> TYPE ❑Full sealing of joints. ❑Blower door test.Cl Exterior air <br /> infiltration barrier <br /> ❑Site-Built ❑Concrete 10.PLUMBING 13.HEAT LOSS(Calculated) <br /> 2.AREA INVOLVED ❑Manufactured ❑Masonry Sewer <br /> ❑Treated Wood ❑Municipal Envelope BTU/HR <br /> Unfin.Bsmt sq ft 5.STORIES ❑Other ❑Septic <br /> ❑ 1-Story 8.USE Permit No. Infiltration BTU/HR <br /> Living Area Sq Ft ❑2-Story ❑Seasonal 11.WATER <br /> ❑Other ❑Permanent ❑Municipal Utility 14.EST.BUILDING COST <br /> Garage Sq Ft ❑Other ❑Private On-Site Well <br /> Total Sq.Ft. ❑Plus Basement $ <br /> I agree to comply with all applicable codes,statutes and ordinances and with the conditions of this permit;understand that the issuance of the permit creates no legal <br /> liability,express or implied,on the state or municipality;and certify that all the above information is accurate. If I am an owner applying for an erosion control or <br /> construction permit,I have read the cautionary statement regarding contractor financial responsibility on the reverse side of the pink ply. <br /> APPLICANT'S SIGNATURE )` "z--r%U± ,11 ? DATE SIGNED / <br /> APPROVAL CONDITIONS This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this <br /> permit or other penalty. <br /> ISSUING ❑Town ❑Village //0 City ❑State of: Municipality Number of Dwelling Location <br /> JURISDICTION '�, . i = �L-_. - <br /> FEES: PERMIT(S) W IS UNIFORM PERMIT ISSUED BY: <br /> ISSUED PERMIT SEAL NO. <br /> Plan Review $ 'e' ❑Construction / , <br /> Inspection $ ❑HVAC Name "7 <br /> Wis.Permit Seal $ ❑Electrical Date `t 7 y <br /> Other $ ❑Plumbing <br /> /� rosion <br /> Total $ /! Mc-I(' ',°- Cert.No. G (CC) <br /> SBD-5823(R.02/97) WHITE-Issuing Jurisdiction YELLOW-State GREEN-Inpsector PINK-Owner/Agent <br />