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Wisconsin Division of <br /> WISCONSIN UNIFORM BUILDING Application No. <br /> Safety and Buildings PERMIT APPLICATION I T7 1k <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) Oct 11 301 'WS 1 2 <br /> PERMIT REQUESTED ❑ Constr ❑ HVAC ❑ Elec ❑ Plbg `I F,rosion Other: <br /> Q ter's Name Mailing Address__ hI S01/Ala' snot Tel $L7(�qti <br /> ,_ ce (kickIofop 7 �f Poivtt Wood s1f#04 <br /> con traa&t rs Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# `['ling Address '}� Te1GaOb- 55-Q2.3.3 <br /> t))t CY-- �(O 5 111.1 2 i0.41 St Bev O'2Od WI 3913 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 5e0%1 S (�,r N 30 a I <br /> Sq.ft. (V 1/4, Cl/4 Section 30 T v t N,R (DIN)W <br /> t ding Address Subdivision Name Lot No. Block No. <br /> y7 it.119 y Ua ley d ---- — <br /> Zo ng District(s) Zoning Permit Front Rear Left Right <br /> /1— I No. Setbacks if 5 ft. ( 5& ft. 2 <;j ft. l t ft. <br /> 1.PROJECT 3.OCCUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE <br /> New ❑Repair ir, ingle Family Entrance Panel ❑Forced Air Furnace Fuel Nat LP Oil Elec Solid Solar <br /> ❑Alteration ❑Raze ❑Two Family Size: amp ❑Radiant Baseboard/Panel Gas <br /> ❑Addition ❑Move ❑Garage Service: ❑Heat Punta%" Space Htg <br /> ❑Other(print): ❑ derground ❑Boiler Water Htg <br /> ❑Overhead ❑Central Air Conditioning *0 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.❑Exterior air <br /> infiltration barrier <br /> Q`Site-Built oncrete 10.PLUMBING 13.HEAT LOSS(Calculated) <br /> 2.AREA INVOLVED I�.�1` an ❑Masonry Sewer <br /> l�(� L ❑Treated Wood ❑Municipal Envelope BTU/HR <br /> Unfin.Bsmt sq ft 5.STORIES ❑Other `Septic <br /> CI ii i�1. -Story 8.USE Permit No. Infiltra[io BTU/HR <br /> Living Area maZti q Ft ❑2-Story ❑Seasonal 11.WATER <br /> (� ❑Other --+ permanent El Municipal Utility 14.EST.BUILDING COST <br /> Garage t O Sq Ft ❑Other ,`Private On-Site Well 1f� <br /> Total 33 -7(o Sq.Ft lus Basement $ 00 <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 Jl - 1\4 1„ < DATE SIGNED r - - %! - cr <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 /> 43Pef LA j i� N A ` _ <br /> PICA.AA <br /> ISSUING ❑Town ❑Village ❑City ❑State of: C 0 LAN)-f..! Municipality Number of Dwelling Location <br /> JURISDICTION it•,) - <br /> FEES: PERMIT(S) WIS UNIFORM PERMIT ISSUED BY: <br /> ISSUED PERMIT SEAL NO. �i <br /> Plan Review $ ❑Construction _r <br /> Inspection $ ❑HVAC Name `,' '''' <br /> Wis.Permit Seal $ ❑Electrical <br /> Other $ ❑Plumbing (C6)(03.3 Date <br /> if gyp° ;rosion fr <br /> Total $ i f V Cert.No. �/' r ti - <br /> SBD-5823(R.02/97) WHITE-Issuing Jurisdiction YELLOW-State GREEN-Inpsector PINK-Owner/Agent <br />