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APPLICANT- PLEASE DO NOT SEPARATE THIS FORM. Your copy will be returned to you with your permit. <br /> ___._.—JO-HNSON1tR r TION LLC w__.._. _ perm No. <br /> PO Box 127 UNIFORM APPLICATION <br /> Arena,WI 53503 BUILDING PERMIT <br /> Phone:608-444-0372 Wisconsin Statutes 101.63, 101.73 Project Description: <br /> The Information you provide may be used by other government <br /> johnsonlnspection@gmoll.com agency programs.I(hivocy Law,S.15.04(1)(m)I <br /> PERMIT REQUESTED I "Construction "HVAC "Electric "Plumbing "Erosion Control "Other: <br /> Owner's Name: Moiling Address: Tel.and Email <br /> Andrew J.Stokes 505 Pine Tree Rd, Kohler WI 53044 tizoa24.7e32 laletokese tatm4it.corn <br /> _Contractor Nome 8,Type Uc/Certlf Mang Address el.8,fax <br /> Dwelling Contractor(Constr.) <br /> Dwelling Contr.Qualifier The Dwelling Contractor Ouolfier shall be an Owner. <br /> CEO.COB or Employee of the Dweling Controctor <br /> HVAC Contractor's Nome: <br /> Electrical Contractor's Name: <br /> Plumbing Contractor's Nome: <br /> PROJECT tot oreo <br /> 10000 Sq lt• One acre or more of <br /> , <br /> LOCATION soil will be disturbedNo SE 1/4, SE 1/4.of Section 21 .1' 09 N.R 06 Edo()W• <br /> Site Address: Subdivision Name: Lot No. Block No. <br /> 10434 Law's Drive Town of Mazomanie,Dane County WI 1 <br /> Zoning Districtjs) I Zoning Permit No. (I Setbacks: (Front Rear I Left I Right <br /> A-1EX 1 ft. ft. ft. ft. <br /> 1.PROJECT 3.OCCUPANCY 6.ELECTRICAL f.HVAC EQUIPMENT 12.ENERGY SOURCE <br /> -New -Sngte Family Entrance Panel -Forced Air Furnace Fuel Not cos - on Etec I Sold !Sec <br /> -Alteration -Repoir X -Two Family Amps: -Radiant eo,•boordtPona Space mto 0 la _ Q I 0 I 0 <br /> 'Addition 'Raze -Commerciol 'Underground X -Heat Pump water wiz f l I 0 U Ii T 0 1 a <br /> "Other. -Move "Goroge "Overhead "Boller <br /> -Other. X 7.WALLS -Central Air Cond. <br /> 2.AREA INVOLVED 14.CONST.TYPE wood Frame -titepbce <br /> X -Othor. 13.HEAT LOSS <br /> "Site-Built -Timber/Pore <br /> Bsmt n/a Sq Ft -Mfd: -wl UDC -Steel -ICF 10.SEWER BTU/HR Total Calculated <br /> Uving 500 -U.S.HUD -Other: 'Municipal Envelope and Infiltration Losses('Maximum Allowable <br /> Sq Ft 5.STORIES 8.USE -Sanitary Permit No.: Heating Equipment Output'on Energy Worksheet: <br /> Goroge n/a Sq A -1-Story X -Seasonal X 'fotol Building Heating Load"on WtScheck report) <br /> -2-Story -Permanent 11.WATER 14.EST.BUILDING COST w/o LAND <br /> Other n/a SgFt -Other "Other: -MunkpolUtifty <br /> Total 500 5q Ft "P:us Basement 'Private On•Slte Wel, $ 1500.00 <br /> I understond thafi om subject to oil applicable codes.statutes and ordinances and with the conditions of this permt;understand that the issuance ofihe permit <br /> creotes no legal labiity,express or Rmpied.on the stole or municipally;and certify that alt the above information is accurate_N one acre or more of soil will be <br /> disturbed.I understand Mot this project is subject to ch.NR 151 regarding additional erosion control and stormwater management and the owner shall sign the <br /> statement on the back of the permit If not signing below.I expressly grunt the building inspector,or the Inspector's authorized agent,permission to enter the premises <br /> for which this permit is sought at of reasonable hours and for any proper purpose to Inspect the work which Is being done. <br /> I vouch that I am or will be an owner-occupant of this dwelling for which I am applying for on erosion control or construction permN without a Dwelling <br /> Contractor Cer$Ncatbn and have read the ca of mint regarding contractor responsibility on the reverse side of the last ply. <br /> APPLICANT'S SIGNATURE DATE SIGNED August 2nd,2017 <br /> APPROVAL CONDITIONS This permit is issued pursuant to the following conditions.Failure to comply moy result in suspension or revocation <br /> of this permit or other penalty.-See attached for condition of approval <br /> -Town of -Visage of -qty of -Co.nly of "State State Contracted Inspection • Municipally Number or Owelrng Location <br /> ISSUING JlII11SOIC11ON ( Agency/ —— ——— <br /> FEES: INSPECTIONS REQUIRED WI PERMIT SEAL I PERMIT ISSUED BY: <br /> Pion Review$ Footing "Underfloor Plumbing/test <br /> inspection j -Foundation -OS Sewer Lateral/test Name <br /> "Rough Construction -Electric Service Date Tel. <br /> WI Seal $ _ "Rough Electrical '1rstgotion <br /> Other S -Rough HVAC "Final Cert No. <br /> TOTAL $ Rough Plumbing/test <br /> RECEIPT: 1 Check I: From: Rec'd by: Date: <br /> Distnbution "white:File "Yellow:Department of Commerce "Pink:Municipally -Gold:Applicant Rev. 11-08 <br />