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Wisconsin Division WISCONSIN UNIFORM BUILDING Application No. of Safety and Buildings PERMIT APPLICATION Wisconsin Stats. 101.63, 101.73 Instructions on back of second ply.The information you provide may be Parcel No. used by other government agency programs[(Privacy Law,s. 15.04(1)(m)] PERMIT REQUESTED ❑ Constr. ❑ HVAC ❑ Electric ❑ Plumbing ❑ Erosion Control 0 Other: Owner's Name Mailing Address 5-3"/i 3 Tel. e C t A t Ce, 6D11 v\ t-/9:, .1-4-01-u12-1S Lk .4.t,-:, (-6-r& -, m64-i,50-11 , lz;l ices,Z- <2.55- SS( 3 Contractor's Name: QCon ❑Elec OHVAC ❑Plbg Lic/Cert# Mailing Address Tel t•/5(,:t3 N-14a8' 051004- I Lire ors- -le t91. rn010i l E. i)11.@., _1-a-c --4-64 s ,inc. /1 3 S ei FLTY■lit.C-I L. C.Cw, W 1 .51/Ci 31 Fipt�5# a-1 (033 Contractor's Name: OCon ❑Elec OHVAC 0 Plbg Lic/Cert# Mailing Address Tel. FAX# Contractor's Name: ❑Con OElec OHVAC 0 Plbg Lic/Cert# Mailing Address Tel. FAX# Contractor's Name: []Con OElec DHVAC 0 Plbg Lic/Cert# Mailing Address Tel. FAX# PROJECT Lot area ❑One acre or more of LOCATION Sq.ft. soil will be disturbed 1/4, _ 1/4, of Section ,T N,R E(or)W Building Address Subdivision Name Lot No. Block No. '-/9 7. /-It,n c...t S u.c.k.-i t, (....0,-4....2..... _ hi t.L.CLi 1• I)1 C bi i .-.' 4-kw-L., Pei-''k, 4q.2. Zoning District(s) Zoning Permit No. Setbacks: Front Rear Left Right /o ft. /0 ft. /FS ft. i? ft. 1.PROJECT 3.OCCUPANCY 6.ELECTRIC 9.HVAC EQUIP. 12.ENERGY SOURCE .i'New 0 Repair 5...Single Family Entrance Panel tPFumace Fuel Nat Gas LP Oil Elec Solid Solar 0 Alteration 0 Raze ❑Two Family Amps: /00 0Radiant Basebd Space Htg ✓ ❑Addition 0 Move 0 Garage B'Underground ❑Heat Pump Water Htg `. Other ❑Other: ❑Overhead ❑Boiler ❑Dwelling unit has 3 kilowatt or more in electric space /11 14 ..L1 j f-&U C,Li t . 7.FOUNDATION OCentral AC heating equipment capacity. 2.AREA INVOLVED(sq ft) 4.CONST.TYPE 0 Concrete ❑Fireplace Unit 1 Unit 2 Total 0 Site-Built ❑Masonry ❑Other: 13.HEAT LOSS Unfin. OMfd.per WI UDC 0 Treated Wood Bsmt LROlfd.per US GYOther: P IAJ 10.SEWER µt. BTU/HR Total Calculated Living HUD l PS F . ❑Municipal Envelope and Infiltration Losses("Maximum Allowable Area (Fi 1 5.STORIES 8.USE 0Sanitary Permit# Heating Equipment Output"on Energy Worksheet; Garage Cif-Story 0 Seasonal "Total Building Heating Load"on Rescheck report) Deck ❑2-Story gePermanent 11.WATER 14.EST.BUILDING COST w/o LAND 0 Other. 0 Other: 0 Municipal $ Totals ❑Plus Basement ❑On-Site Well 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 liability, express or implied.on the state or municipality;and certify that all the above information is accurate.If one acre or more of soil will be disturbed,I understand that this project is subject to ch.NR 151 regarding additional erosion control and stomiwater management. If I am an owner applying for an erosion control or construction permit,I have read the cautionary statement regarding contractor financial responsibility on the reverse side of the last ply.I expressly grant the building inspector,or the inspector's authorized agent,permission to enter the premises for which this permit is sought at all reasonable hours and for any proper purpose to inspect the work which is being done. APPLICANT'S SIGNATURE C(i►t_c1 -zt-r..1 L6-4-e"c-a-u`-emu J a,v DATE SIGNED R/3/O"l APPROVAL CONDITIONS This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this permit or other penalty. 0 See attached for conditions of approval. ISSUING OTown of ❑Village of OCity of (County of `State-• State-Contracted Inspection Municipality Number of Dwelling Location Agency#: JURISDICTION - FEES: PERMIT(S)ISSUED WIS PERMIT SEAL# PERMIT ISSUED BY: Plan Review $ 0 Construction Inspection $ 0 HVAC Name Wis.Permit Seal $ iI Electrical Other $ l.1 Plumbing Date Tel. H Erosion Control Total $ Cert No.