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State of Wisconsin <br /> . - Department of Industry, WISCONSIN UNIFORM <br /> Labor&Human Relations ^ <br /> Division of Safety&Buildings BUILDING PERMIT APPLICATION NO.—) <br /> Box 7969 <br /> Madison WI 53707 APPLICATION f t 1 T a t , <br /> Wisconsin Statutes 101.63 101.73 (See Instructions on back of pink copy) PARCEL NO. C 1 L <br /> REKNIT REQUESTS#? <br /> CONSTRUCTION RIHVAC LELEC IN PLUMBING OTHER: <br /> Owner's Name Mailing Address <br /> f\ n j� Telephone <br /> \ t^ _ f> Z 7 `-a 't•):1,.-{L,_.,M, f t . . ', 3-• ,,. f J': , e t t` (. vi Z. j <br /> Contractor's Name t ti � <br /> r t Mailing Address Telephone <br /> PROJECTLOCATION 1LotArea <br /> Sq.ft. W iNr �% Al" %a,SECTION Z <br /> Building Address <br /> Subdivision Name T N,R E(or)W <br /> 2.-1 # '. \_/■'\k.... /.` k C .J Y r\ i ( Lot No. Block No. <br /> Zoning District(s) YZoning Permit No. Front t <br /> Rear Left g <br /> ,�t _ ( / t t `f - 4J ? -> -"',a , <" Right <br /> 1. PRO,II GT Setbacks ft. ft. I `, ft. , , <br /> 9 Occupanicyt 6.i:ELECTRICAL 9. HVAC:EQUIPMENT i2 ENERGY SOURCE ft.•!'i New ❑ Repair I Single Family Entrance Panel <br /> •Alteration ❑ Raze Radian Air Furnace Fuel Nat. L.P. Oil Elec.Solid Solar <br /> ❑Two family Size: �- �'b amp ❑ Radiant Baseboard or Panel Gas * <br /> ❑Addition ❑ Move ❑Garage Service: <br /> ❑Other ❑ Heat Pump Space Htg. ❑ ❑ ❑ El ❑ <br /> ©Underground ❑ Boiler <br /> ❑Overhead Water Htg. ❑ 1:1 ❑ ❑ El ❑ <br /> ❑ Central Air Conditioning <br /> ❑Other 4 CONST TYPE 7. FOUNDATION ❑ Other * ❑Dwelling unit will have 3 kilowatt or <br /> more installed electric space heating equip. <br /> Site constructed Concrete 10. PLUMBING <br /> r r Mason _ Infiltration control option is ❑Full sealing <br /> 0.':':,,...:::q:.':;:•:.:.::::' ❑Manufactured ry Sewer of joints. ❑Blower door test. ❑Exterior <br /> ❑Treated Wood Municipal air infiltration barrier. <br /> ❑Other <br /> nfinished Basement /?�`-3q.ft. 5 STORIE5 � Septic I 13, HEAT LOSS } <br /> Cl 1 Story USE Permit No 1 't~ GalCUlaFed <br /> Living Area _ g Y <br /> q•ft• Envelope BTU/HR <br /> m,2 Story ❑ Seasonal jt, WATER <br /> Garage (.Li`Z S ❑ #they Infiltration <br /> q.ft. Permanent BTU/HR <br /> ❑Other ❑ Municipal Utility 74, ;EST.I fII"DIN GOS1 <br /> i.1 r F `' • Plus basement Private on-site Well <br /> ti- <br /> $ / (3 ) N �, <br /> Th- :•'licant agrees to comply w' all applicable codes,statutes and ordinances and with the conditions of this permit;understands that the issuance of the <br /> permit crea es • _: •_: ',express or implied,on the Department or Municipality;and certifies that all the above information is accurate. <br /> • <br /> SIGNATURE OF APPLICANT ' r , .Y <br /> �; DATE ;'` <br /> r ' <br /> CONDITIONS OF APPROVAL This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or <br /> revocation of this permit or other penalty. <br /> .................. <br /> ISSUING TOWN ❑VILLAGE ❑CITY ❑ COUNTY Municipality Number of Municipality Number of Dwelling <br /> STATE ❑INDEPENDENT Inspection Authority Location,if different <br /> JURISDICTION OF: -.r • -A L <br /> —-ADZ. <br /> FEES: PERMITS) WIIS,UNIFORM:PERMIT —— ——• ISSU ;SEAL[440. < PERNt1T'ISSUED:.BY: <br /> Plan Review--> . $ (/'? , c'a� Construction <br /> Inspection , $ HVAC NAME ` 1� <br /> 'Q Electrical -� ;'c i 1. .) -- <br /> Wis.PermitSeal $ fl Plumbing <br /> Other $ ?7' `� ,Other DATE <br /> TOTAL $ -T . v`?, .,`e _r CERT.NO. ( ;z . <br /> SBD 5823(R.8/90) WHITE—Issuing Jurisdiction YELLOW—DILHR <br /> GREEN—Inspector PINK—Owner/Agent.. <br />