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Wisconsin Division of WISCONSIN UNIFORM BUILDING Application No. <br /> Safety and Buildings PERMIT APPLICATION ( t) (c)-375 G <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) !Z.— 0"312— / 3— ' <br /> PERMIT REQUESTED ❑ Constr ❑ HVAC ❑ Elec ❑ Plbg XErosion Other: <br /> Ares P Mailing Addres e , Tel-11144 Z) <br /> J 1 c! 225 .t y r e_t 131 v c)43 FAX �� <br /> Con actor's Name: n ']Elec ❑HVAC❑Plbg Lic/Cert# Mailing Addrre,ss' r�ff Co,-Hoy Tel.&cs-$3q-153/r <br /> — %,)v'es S c te_ Co>-t S 1 r u ct' 1�3S k- 1 7 td . 04 ,.) , (�10�c FAX6OS S3 1-4671 <br /> Contractor's Name: ❑Con ❑Elec ❑HVAC❑Plbg Lic/Cert# ailing 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 area 5AC N W j 9 Q /-fin ) <br /> ft. I/4, 1/4 Section 11 ,T U N,R 126(or)W <br /> Building Address Subdivision !v Name �A �0� Lot No. Block No. <br /> 1570 R <br /> Zoning District(s) Zoning Permit.�n Fiont ear Left Ri �''�' <br /> VV t,m''7 ( ) Nom — I�j14Setbacks l��ft. ft. S ft. g�L�tC� ft. <br /> 1.PROJECT 3.00�L ICUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE <br /> '14,.,New ❑Repair sg,Single Family trance Panel El reed Air Furnace Fu 1 Nat LP Oil Elec Solid Solar <br /> ❑Alteration ❑Raze ❑Two Family Siz amp ❑Ra t Baseboard/Panel Gas <br /> ❑Addition ❑Move ❑Garage Service. ❑Heat Pu Space Htg <br /> ❑Other(print): ❑Undergr d ❑Boiler '�_ Water Htg <br /> ❑Overhead ❑Central Air Condit' 'ng *❑Dwelling unit will have 3 att or more installed <br /> ❑Other —4.CONST. 7.FOUNDATION ❑Other electric space heating equip.Infiltratio trol option is <br /> TYPE ❑Full sealing of joints. ❑Blower door test. 'or air <br /> infiltration barrier <br /> `.Site-Built Aoncrete 10.PLUMBING 13.HEAT LOSS(Calculated) <br /> 2.AREA INVOLVED ❑Manufactured ❑Masonry Sewer <br /> — <br /> 50 ❑Treated Wood ❑Municipal Envelope BTU/HR <br /> �` <br /> Unfin.Bsmt ) 0 sq ft 5.STORIES ❑Other `Septic q 7_O3 <br /> 7 ❑1-Story 8.USE Permit No. l� nfiltration BTU/HR <br /> Living Area`t OQ Sq Ft -Story ❑Seasonal 11.WATER <br /> ❑Other %Permanent ❑Municipal Utility 14.EST.BUILDING COST <br /> Garage 5 7G Sq Ft ❑Other Private On-Site Well <br /> Total _Sq.Ft. XPlus Basement $ 132 6'S . GO <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 DATE SIGNED <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 /> i S eei St -IC <br /> P r-------------c-t A <br /> ISSUING l fown ❑Village ❑City ❑State of: Municipality Number of Dwelling Location <br /> JURISDICTION (A E.I N A . ,N;6 CD/gory - <br /> FEES: <br /> PERMIT(S) IS UNIFORM PERMIT ISSUED BY: <br /> ISSUED PERMIT SEAL NO. F <br /> Plan Review $ ❑Construction Name `fir (---- <br /> Inspection $ ❑HVAC ,d <br /> Wis.Permit Seal $ ❑Electrical mbin E(.0.3 -2 , 7 -.Other $ ❑Plumbing Date � <br /> I 1j �� opton Cert.No. s! I Total $ (� <br /> SBD-5823(R.02/97) WHITE-Issuing Jurisdiction YELLOW-State GREEN-Inpsector PINK-Owner/Agent <br />