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1. Wisconsin Division WISCONSIN UNIFORM BUILDING Application No. o€Safety and Buildings PERMIT APPLICATION QZ 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)] �Lc �g�_ . 2 e �; PERMIT REQUESTEDonstr. ❑ HVAC ❑ Electric ❑ Plumbing osion Control Other: Mm $ _ Tel lO0P 'AIU J I) /-7 l (U 1/ Lf0U/C L OSYCiOf Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg LSc/Cert# Mailing Address Tel. E - ? , 80,\-- /0 (. -7mi,66 ‘,/,,,ye# Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. FAX# Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. FAX# Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. FAX# PROJECT Lot area LOCATION Sq.ft. //tAI 1/4, /U.L4-1/4, of Section a p,T 7 N,R 0\E(or)W BG 1 p7dds/t ��H� 4 P Subdivision�N/14 /. Lot No. Block Nom Zoning District(s) yyrr Zoning Permit Nof.// "( Setbacks: Front Rear p( Left Right /Fr 3 `f ' /O`1' 6 Zo( ft. /Z ft. 1,72 ft. /7 ft. 1.PROJECT 3:OCCUPANCY 6.ELECTRICAL 9:HVAC EQUIPMENT 12.ENERGY SOURCE ANew ❑Repair 6-frtgle Family Entrance Panel ❑Forced Air Furnace Fuel Nat Gas LP Oil Elec Solid Solar ❑Alteration ❑Raze d Two Family Amps: ❑Radiant Basebd/Panel Space Htg ❑Addition ❑Move ❑Garage ❑Underground ❑Heat Pump Water Htg ❑Other. ❑Other. ❑Overhead ❑Boiler ❑Dwelling unit has 3 kilowatt or more in electric space 7.FOUNDATION ❑Central Air Cond. heating equipment capacity. 2.AREA INVOLVED 14.CONST.TYPE ❑Concrete ❑Other: 13.HEAT LOSS Unfin. ❑Site-Built ❑Masonry Bsmt Sq Ft ❑Mfd: ❑WI UDC ❑Treated Wood 10.SEWER BTU/HR Total Calculated Living ❑U.S.HUD ❑Other: ❑Municipal __ Envelope and Infiltration Losses("Maximum Allowable Area Sq Ft 5.STORIES 8.USE ❑Sanitary Permit No Heating Equipment Output"on Energy Worksheet; ❑ 1-Story ❑Seasonal "Total Building Heating Load"on WlScheck report) Garage Sq Ft ❑2-Story ❑Permanent 11.WATER 14.EST.`BUILDING COST ❑Other. ❑Other: ❑Municipal Utility Deck Sq Ft. ❑Plus Basement ❑Private 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 I am an owner applying for an erosion control or construction permit, I have read the cautionary statement regarding contractor financial respo s ibility on the reverse side of the last ply.I expressly grant the building inspector,or the inspector's authorized agent,permission to enter the premi es for which this permii)ought at all reasonable hours and for any proper purpose to inspect the wor which is being do APPLICANT'S SIGNATURE ��tl% r �e . DATE SIGNED/—/Z APPROVAL CONDITIONS This pe .0 's-issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this permit or other penalty. ❑ See attached for conditions of approval. ISSUING 'own of ❑Village of ❑City of ❑County of ❑State Inspection Agency#: Municipality Number of Dwelling Location JURISDICTION !Y i �V/IIt)I - FEES: /f PERMIT(S)ISSUED WIS PERMIT SEAL# PERMIT'ISSUED-HY: Plan Review $ ❑ Construction �� Inspection $ ❑HVAC N.a.. //�.r Wis.Permit Seal $ ❑Electrical Other $ ❑Plumbing Date,////CV Tel. osion Control ` Total $ //0 Cert No. �.-e97d7 SBD-5823 (R.4/02) Distribution: ❑Ply 1-Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Inspector ❑Ply 4-Applicant ISSUING JURISDICTION