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Wisconsin Division WISCONSIN UNIFORM BUILDING Application No. <br /> of Safety wad Buildings PERMIT APPLICATION a f z 7 3 <br /> Wisconsin Stats. 101.63,101.73 Instructions on back of second ply.The information you provide may be Parcel No. <br /> used by other government agency programs(Privacy Law,s. 15.04(1)(m) !)9/z 34/ it 3 G 7 0 <br /> PERMIT REQUESTED ❑ Constr. ❑ HVAC ❑ Electric ❑ Plumbing ❑ Erosion Control Other: <br /> Owner's Mailing A ` <br /> Tel. <br /> ) (;)(IRO 1 k— �� � R — c ' • 51 0 5aI u_3°y <br /> 0 <br /> t� , c111GGGContractor's Name: 9Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# MailingAddress rb �1p- .te, btoe;s-3095- <br /> CR c JL Coy fit. A - A i s3ss A <br /> Contractor's Name: ❑Con JylElec ❑HVAC ❑Plbg Lic/Cert# Mailing Address P 11 4 1 '� 1 Fi <br /> On tl. t.-6k\'‘u t t <br /> Contractor's Name: ❑Con ❑Elec 4IVAC ❑Plbg Lic/Cert# Mailing.Address Tel. <br /> ! <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC .lbg Lic/Cert# Mailing Address Tel. <br /> fr y <br /> FAX <br /> PROJECT Lot area <br /> LOCATION Sq.ft. td 1/4, f E 1/4, of Section 7 if ,T '' N,R /Z. E(or)W <br /> Building Address - Subdivision Name Lot No. Block No. <br /> Zoning District(s) Zoning Permit No. I Setbacks: Front Rear Left Right <br /> ft. ft. ft. ft. <br /> 1.PROJECT 3.00CUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE <br /> lew ❑Repair Ingle Family Ent c anel QAForced Air Furnace Fuel Nat Gas LP Oil Elec Solid Solar <br /> ❑Alteration ❑Raze ❑Two Family Amps: Radiant Basebd/Panel Space ace Ht g ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑Addition ❑Move ❑Garage ❑Underground ❑Heat Pump Water Htg ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑Other: ❑Other: ❑Overhead ❑Boiler 0 Dwelling unit has 3 kilowatt or more in electric space <br /> 7.FOUNDArI)N ❑Central Air Cond. heating equipment capacity. <br /> 2.AREA INVOLVED I 4.CONST.TYPE I"Concrete ❑Other: 13.HEAT LOSS <br /> Unfin. ite-Built ❑Masonry <br /> J� okl 10.SEWER BTU/HR Total Calculated <br />{ Bsmt � Sq Ft �Mfd: ❑WI UDC 0 Wo <br /> Living(\/ _ ❑U.S.HUD ❑Other: 0 Municipal Envelope and Infiltration Losses("Maximum Allowable <br /> Area ri d W.1 Sq Ft ''5.STORIES 8.USE ❑Septic Permit No.: Heating Equipment Output"on Energy Worksheet; <br /> PM-Story ❑Seasonal 1 "Total Building Heating Load"on Wischeck report) <br /> Garage Sq Ft 11'2-Story % Permanent 11.WATER 14 EST.BUILDING COST <br /> ❑Other: ❑Other: ❑Municipal Utility <br /> Deck Sq Ft. ❑Plus Basement ❑Private On-Site Well $ <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 I am an owner applying for an erosion control or construction permit, <br /> I have read the cautionary statement regarding contractor f ancial resp•nsibility on the reverse side of the last ply.I expressly grant the building inspector,or the inspector's <br /> authorized agent,permission to enter the premiss +r i•' this pe i s i ought at all reasonable hours and for any proper purpose to inspect the work which is being done. <br /> APPLICANT'S SIGNATURE II ; . ■ A.11.1.. DATE SIGNED 10 el- 6/` <br /> This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this <br /> APPROVAL CONDITIONS permit or other penalty. <br /> i <br /> ISSUING ❑Town ❑Village ❑City ❑State of: Municipality Number of Dwelling Location <br /> JURISDICTION / I - 6 7 t) <br /> FEES: PERMIT(S)ISSUED WIS PERMIT SEAL# PERMIT ISSUED BY: <br /> Plan Review $ ❑ Construction <br /> Inspection $ I 1 7' UCJ ❑HVAC - j Name S,p Si 6 <br /> ✓,.r •Cr. Y <br /> Wis.Permit Seal $ ❑Electrical [, Z <br /> Other S ❑Plumbing I 'u Date '4-9 C)`Z,,.Tel. Z a - it,'7l <br /> ❑Erosion <br /> Total $ /10 •©D Cert No. h52. —7r/ / <br /> SBD-5823(R.10/99) INSPECTOR <br />