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APPLICANT- PLEASE DO NOT SEPARATE THIS FORM. Your copy will be returned to you with your permit. <br /> JOHNSON INSPECTION LLC UNIFORM APPLICATION Permit No. <br /> PO Box 127 BUILDING PERMIT <br /> Arena,WI 53503 _ <br /> Phone:608-444-0372 Wisconsin Statutes 101.63, 101.73 Protect Description: <br /> The information you provide may be used by other government k e side-n/74,( <br /> johnsoninspection @gmail.com agency programs.[(Privacy Law,S.15.04(1)(m)] 4-cces,sory ,8cr:,LLt'c' ) <br /> PERMIT REQUESTED I Construction •HVAC electric Plumbing Erosion Control i_Other: <br /> Owner's Name: Mailing Address: ( c '-q37- .Z7 h <br /> • Tel. <br /> 6fe Mien E'%7ebraA. (rv,J r a7785 Nor u eevar1 7/. Mt fi�re.icrJ� �35'7� 4,oY-37c�-07,5'a <br /> Contractor Name&Type Uc/Cert# Mailing Address Tel.&Fax <br /> Dwelling Contractor(Constr.) <br /> -13j 6" Chris NcL Ma.r- Rd 608-935-.. 3 S'it- <br /> /no rfor) J3LLI LLhis /�odc�'Jr//� w� 5 S':33 <br /> Dwelling Contr.Qualifier The Dwelling Contractor Qualifier shall be an Owner. 6 O 6-5 75--'7 6,6, 2. <br /> /ra t'/5 HQ/Yer3O ) CEO,COB or Employee of the Dwelling Contractor <br /> HVAC Contractor's Name: <br /> nr/4 <br /> Electrical Contractor's Name: - <br /> .d ciJ-c.1-miner/ (SIOruny) <br /> Plumbing Contractor's Name: <br /> N/A <br /> PROJECT Lot area <br /> One acre or more of <br /> LOCATION 037,3 Sq ft soil will be disturbed <br /> .5 GL) 1/4,_5(l) 1/4,of S ection j ,T E N,R 7 ©(or)W <br /> Site Address:ss: Subdivision Name: Lot No. Block No.mil 9er 1V0 r-ruf en T14. i .lfe <br /> Zoning District(s) Zoning Permit No. Setbacks: Front Rear Left Right <br /> A-L '30 ft. ,/G <br /> Do ft. _ .76 ft. T?c, ft. <br /> 1.PROJECT 3.OCCUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE <br /> New C Single Family Entrance Panel ❑Forced Air Furnace Fue! Nat Gas LP Oil Elec Solid Solo' <br /> :3 Alteration C Repair 3 Two Family Amps: /[17 :3 Radiant Baseboard/Panel Space Htg <br /> C Addition C Raze -Commercial s.Underground 31 Heat Pump Water Hta <br /> 2 Other: C Move C Garage / C Overhead 0 Boiler <br /> l'COther:SIC r e-ge-Spa 7 Central Air Cond. <br /> 7.WALLS <br /> Fireplace <br /> 2.AREA INVOLVED 4.CONST.TYPE Wood Frame 0 Other: 13.HEAT LOSS <br /> Site-Built C Timber/Pole <br /> Bsmi Sq Ft '7 Mfd: C WI UDC IC Steel ICF 10.SEWER BTU/HR Total Calculated <br /> Living ❑U.S.HUD C Other: ❑Municipal Envelope and Infiltration Losses("Maximum Allowable <br /> Area Sq Ft 5.STORIES 8.USE :1 Sanitary Permit No.: Heating Equipment Output"on Energy Worksheet: <br /> Garage Sq Ft 1-Story ri Seasonal "Total Building Heating Load"on WlScheck report) <br /> ) <br /> 2-Story $Permanent 11.WATER 14.EST.BUILDING COST w/o LAND <br /> Others 71p Sq Ft _Other: I1 Other: Ti Municipal Utility tl <br /> Plus Basement Private On-Site Well <br /> Total_ Sq Ft $ �S Do0 <br /> I understand that I am subject to all applicable codes,statutes and ordinances and with the conditions of this permit;understand that the issuance of the permit <br /> creates no legal liability,express or implied,on the state or municipality;and certify that all the above information is accurate.If one acre or more of soil will be <br /> disturbed,I understand that 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 grant the building inspector,or the inspector's authorized agent,permission to enter the premises <br /> for which this permit is sought at all 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 an erosion control or construction permit without a Dwelling <br /> Contractor Cert'if'ication and have read the cautionary statement regarding contractor responsibility on the reverse side of the last ply. <br /> APPLICANT'S SIGNATURE(Q-c fg,_ 2. sheer .C:f: � DATE SIGNED /D --a3-/7 <br /> APPROVAL CONDITIONS This permit is issued pursuant to the following conditions.Failure to comply may result in suspension or revocatior <br /> of this permit or other penalty. See attached for conditions of approval. <br /> Town of Village of City of County of State State Contracted inspection Municipality Number of Dwelling Location <br /> ISSUING JURISDICTION .Agency# <br /> FEES: INSPECTIONS REQUIRED WI PERMIT SEAL# PERMIT ISSUED BY: <br /> Plan Review$ Footing Underfloor Plumbing/test <br /> Foundation OS Sewer Lateral/test Name <br /> Inspection $ Rough Construction Electric Service <br /> WI Seal Date Tel. <br /> $ Rough Eiectrical 'insulation <br /> Other $ :Rough HVAC Final Cert No. <br /> TOTAL $ Rough Plumbing/test <br /> ' - <br /> !RECEIPT: Check#: From: Rec'd by: Date: <br /> Distribution .White:File Yellow:Department of Commerce Pink:Municipality Gold:Applicant Rev. 11-08 <br />