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09-18-'08 09:45 FROM-Town of Verona
<br /> . 6088457143
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<br /> • . T-363 P002/005 F-773
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<br /> Wisconsin Division WISCONSIN UNIFORM BUILDING Application No.
<br /> of Safety and Buildings P r- 13
<br /> PERMIT APPLICATION
<br /> Wisconsin Stats.101.63,101.73 Instructions on back of second ply.The information you proviodoe4maoy(bc)) ParceiNo. Ot
<br /> used by other government agency programs[(Privacy Law,s. . )m r ..-
<br /> -----T—r---T---,---- , ..,7".-71, 010.1"
<br /> P',..; ! .. :1RE 8 U:ES ::2‘;'. Constr. HVAC Electric Plurnbin: Erosion Control Other:
<br /> Owner Imee t,...,..p j, i ;c, , . 111S9diess loti Cue/..6.1. • T.1.
<br /> 4 ,61.0 45ktz
<br /> :COntractitr Nati 147.1)+Iii: '::: :::: .:'.. ::: : ::::. i: :LictOorOf: !r:ii 'Mailing::".. --,': ::1 .:!: '• : : .; : :i, •irrel:*Eisit .:1':
<br /> Dwelling Contractor(Constr.) 6ot-f -,r6 7 y
<br /> li)ciettri.K ._i • -
<br /> .
<br /> • ... AK. ‘si'r umitLep f, v ,:-• At 0-1.V' _.:--iii.s---/.3_53-
<br /> Dwelling Contr.Qualifier The Dwelling Contr.Qualifier shall be an owner,
<br /> COB or employee of the Dwelling Contr.
<br /> I-1VAC
<br /> ----------
<br /> Electrical ---
<br /> Plumbing •
<br /> ----
<br /> .9#P17. :,..-•; Lot arra One acre or more of
<br /> f.ADetilette0:; kft. soil will be disturbed
<br /> i 1/4, 1/4, of Section ,r N,R E.(or)W
<br /> Bfiilding Address ., Subdivision Name Lot No. 1 Block No.
<br /> 63W WHALOtt V ET ZOti A 4-JV
<br /> Zoning District(s) Zoning Permit No. —„-----
<br /> Setbacks: ' Front Rear Left Right
<br /> ftj ft. ft.
<br /> 3,
<br /> I AN OV:::. :it '.1.' ' C :::: V::1 AC' 11/1Pw: ::It YWORCE:
<br /> New Repair Single Family Entrance Panel Furnace Fuel Nat Gas LP Vall Bite Solid Solar
<br /> Alteration Raze Two Family Amps! Radiant Basebd Space Htg _ r3 0 0 ci ci p
<br /> Addition Move Garage Underground Heat Pump Water Htg 0 0 0 0 0 0
<br /> Other: Other: Overhead Boiler Dwelling unit has 3 kilowatt or more in electric space
<br /> Central AC heating equipment capacity.
<br /> 2.<_,Aggoowy.opvg,4 ;177.7 :4.14 POBST#ITIT......., wood Prgutte CIFil'Pla"
<br /> . ,.......- --...
<br /> Unit li unit 2 i Total Site-Built Steel Other: '::414)“.4A.k$::: :: '''::!..; ::.,:..:'',W' .:.::::':::•:;!:!: : :,:.,1,..:..;:
<br /> Unfin. Mfd.per WI UDC 0 la
<br /> Bard a.on) Ivird.per US 0 Timber/Pole .:::1032WER : ::... - BT11/IIR Total Calculated
<br /> Living ROD 0 Other: Municipal Envelope and Infiltration Losses("Maximum Allowable
<br /> Area grooE$ i'i;7:::.;::,!i;:ofg:::..::' ::.1:::.7 Sanitary Permit* Beating Equipment Output"on Energy Worksheet:
<br /> '
<br /> Garage I-Story Seasonal "Total Building Heating Load'on Rescheck report)
<br /> neck — 2-Story Permanent :.0.-M-1.4l0777W-01."-- OVCT*fa 1.41W;
<br /> Other; Other: Municipal $
<br /> Totals 0,iii Plus Basement On-Site Well
<br /> -I-- -
<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 liability,
<br /> 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
<br /> project is subject to a.NR 151 regarding additional erosion control and storrnwater management and the owner shall sign the statement on the back of the permit if not
<br /> signing below. 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
<br /> hours and for any proper purpose to inspect the work which is being done.
<br /> I vouch that I am or will be an owner-occupant of this dwelling for which I its applying for an erosion control or construction permit without a Dwelling
<br /> Contractor Certification and have read the cautionary statement regarding contractor responsibility on the reverse side of the Int ply.
<br /> APPLICANT'S SIGNATURE Air %,.2, /1.- 4 DATE SIGNED .2.2 O
<br /> ..-
<br /> APPROVA.L CONDITIONS .is permit is issued pursuant to i. following conditions. Failure to oomply may result in suspension or revocation of this
<br /> • unit or• . . . See attached for conditions of a'.royal.
<br /> . 111111111=111r-
<br /> •.. a ZWEE1211 :ilith' AINZIT4 / id?) mr,
<br /> ISSVINO: :;:;:,.' :;;; .... Pir own of City of County of State-. State-Contracted Inspection Municipality Number of Dwelling Location
<br /> Agency#: / 2 _a 6 .2-)
<br /> try. '" ..,::: ,L!;: ;: : :: :: ::::..: ;: .ItEitterMISSIX! • WIS PROW SEAL IV :1"41711.W1`ISSUED ;': j.;NREIN ?,:.
<br /> Plan Review $ Construction
<br /> inspection $ — _ liVAC Name 041
<br /> Ws.Permit Seal $ Electrical
<br /> Other $ d•-• , Plumbing - 4-0 Data4'...1s14itl. ly5--- 7,F
<br /> Erosion Control PAID
<br /> Total $ - --)-1—‘--. Cert No. 74-)'1Z_2)_______
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<br /> SBD-5823(R.01/08)Distribute: Ply I-Issuing Jurisdiction; Ply 2-Issuer for . 11i State v44 og days; 17-13-- nsictor, Ply 4-Applicant
<br /> 1 TOWN OF VERONA
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