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Wis't;onsin Division WISCONSIN UNIFORM BUILDING Application No. . of Safety and Buildings 39322 PERMIT APPLICATION 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) PERMIT REQUESTED < ❑ Constr. ❑ HVAC ❑ Electric ❑ Plumbing rosion Control Other: Owner's Name Mailing Address _ Tel 6:9."-A,. jai, (. ,-,� /2 y t,.., ... S-r- ) c�f1' ;.v__J �" cc s _ '- cyz-7i 3'2 Contractor's Name: OCon Otlec ❑HVAC Llbg Lic/Cert# Mailing Address Tel. y FAX# Contractor's Name: ❑Cod❑Elec C IVAC.�Plbg Lic/Cert# Mailing Address Tel. D PO yo,L !ff d FAX r ,-C .7/ 1 Contractors Name: lec OHVAC ❑Plbg�Lic/Cert# Mailing Address Tel. ll FAX# ..1P A/ e— n Contractor's Name: lon ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. L- ,- Ca A ju 1 ../(. e- FAX# PROJECT Lot ea ` LOCATION ff. 0( i` Sq.ft. .17.1_ 1/4, ..7:v-11/4, of Section ,T -r ■1,R C Eior)W ! Building Address Subdivision Name Lot No. Block No. Zoning District(s) Zoning Permit No. Setbacks: Front Rear Left Right 14 t-t - Z 1_;,,,vft. '7 ft. /0 ft. (S• ft. 1.PROJECt 3.OCCUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE ❑)New ❑Repair ❑§ingle Family Entrance Panel ❑jorced Air Furnace Fuel Nat Gas LP Oil Elec Solid Solar ❑Alteration ❑Raze ❑Two Family Amps: ❑Radiant Basebd/Panel Space Htg ❑ QK ❑ ❑ ❑ ❑ ❑Addition ❑Move ❑Garage ❑Underground ❑Heat Pump Water Htg ❑ ❑ ❑ ❑ ❑ ❑ ❑Other: ❑Other: 1717Qverhead ❑Boiler ❑Dwelling unit has 3 kilowatt or more in electric space 7.FOUNDATION ❑Central Air Cond. heating equpment capacity. 2.AREA INVOLVED 4.CONST.TYPE ❑)Concrete ❑Other: 13.HEAT LOSS Unfin. ❑Site-Built ❑Masonry Bsmt <t; 77 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 2 S 7Z Sq Ft 5.STORIES 8.USE ❑, anitary Permit No.: Heating Equipment Output"on Energy Worksheet; 01d-Story ❑Seasonal y, } y 4:— "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 Q'rivate On-Site Well $ /YO cJO t7 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 responsibility on the reverse side of the last ply.I expressly grant the building inspector,or the inspector's authorized agent,permission to enter the premises for w.l ich this permit is so}ight at all reasonable hours and for any proper purpose to inspect the work which is being done. APPLICANT'S SIGNATURE �. ". DATE SIGNED U „2,", APPROVAL CONDITIONS This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this j permit or other penalty. ❑ See attached for conditions of approval. I I ISSUING ❑Town of ❑Village of ❑City of ❑teounty of ❑State Inspection Agency#: Municipality Number of Dwelling Location 1 JURISDICTION L I\ r,.t 1-s. FEES: PERMITS)ISSUED WIS PERMIT SEAL# PERMIT ISSUED BY; Plan Review $ ❑ Construction Inspection $ ❑HVAC Name , - Wis.Permit Seal $ ❑Electrical Other $ ❑Plumbing Date --i'. v. ,_:•r Tel. 4-,4 c r� ■ ❑ Erosion Control + Total $ \1 j^' Cert No. i t Fl SBD-5823(R.05/01) Distribution: ❑Ply 1 -Issuing Jurisdiction ❑Ply 2-Municipality Forwards to State If New Dwelling ❑Ply 3-Inspector ❑Ply 4-Applicant INSPECTOR