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` • Wiscojsin Division WISCONSIN UNIFORM BUILDING Application No. of Safety and Buildings PERMIT APPLICATION .. 4,-/(4 7`i ) •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) t'1'' ,' 2 ,{J `)(2)'-) 7 PERMIT REQUESTED ❑ Constr. ❑ HVAC ❑ Electric ❑ Plumbing ❑ Erosion Control Other: Owner's Name Mailing Address Tel. Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. _ --1 � . Fes"`—` - Contractor's Name: ❑Con DElec DHVAC ❑Plbg Lic/Cert# Mailing Address Tel. FAX Contractor's Name: ❑Con ❑Elec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel FAX Contractor's Name: ❑Con DElec ❑HVAC ❑Plbg Lic/Cert# Mailing Address Tel. FAX PROJECT Lot area LOCATION Sq.ft. .''-"' 1/4, " "'`'1/4, of Section ,T N,R E(or)W Building Address Subdivision Name Lot No. Block No. Zoning D,strict(s) Zoning Permit No. Setbacks: Front Rear Left Right II ft. ft. ft. ft. 1.PROJECT 3.OCCUPANCY 6.ELECTRICAL 9.HVAC EQUIPMENT 12.ENERGY SOURCE 9-New ❑Repair ❑Single Family Entrance Panel ❑Forced Air Furnace Fuel Nat Gas LP Oil Elec Solid Solar ❑Alteration ❑Raze ❑Two Family Amps: ❑Radiant Basebd/Panel Space Htg ü ❑ ❑ ❑ ❑ ❑ ❑Addition ❑Move ❑Garage ❑Underground ❑Heat Pump Water Htg ❑ ❑ ❑ ❑ ❑ ❑ ❑Other: ❑Other: ❑Overhead 0 Boiler ❑Dwelling unit has 3 kilowatt or more in electric space 7.FOUNDATION ❑Central Air Cond. heating equipment capacity. 2.AREA INVOLVED °4.CONST.TYPE ❑Concrete 0 Other: 13.HEAT LOSS Unfin. ❑Site-Built ❑Masonry Bsmt Sq Ft 0 Mfd: ❑WI UDC ❑Treated Wood 10.SEWER BTU/HR Total Calculated Living ❑U.S.HUD ❑Other: ❑Municipal Envelope and Infiltration Losses("Maximum Allowable Area Sq Ft 5.STORIES 8.USE ❑Septic Permit No.: Heating Equipment Output"on Energy Worksheet; ❑ 1-Story ❑Seasonal "Total Building Heating Load"on Wischeck report) Garage Sq Ft ❑2-Story ❑Permanent 11.WATER 14.EST.BUILDING COST ❑Other: ❑Other: ❑Municipal Utility 7-- Deck Sq Ft. ❑Plus Basement ❑Private On-Site Well $ y s,_ :_J4 (J 3 —' 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 which this permit is sought at all reasonable hours and for any proper purpose to inspect the work which is being done. APPLICANT'S SIGNATURE I. ,i .{?'.,':e , i" 6,-!.4'7::% DATE SIGNED . APPROVAL CONDITIONS This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revocation of this permit or other penalty. ISSUING - Town ❑Village ❑City ❑State of: Municipality Number of Dwelling Location JURISDICTION "A-. /)//v/ -— — — FEES: PERMIT(S)ISSUED WIS PERMIT SEAL# PERMIT ISSUED BY: Plan Review $ ' ❑ Construction ��`j — /,� (f ` Inspection $ ' ❑ HVAC Name `/ __�i�1 Wis.Permit Seal $ ❑ Electrical /, ; 1 v Other $ ❑ Plumbing ' -1 Date. %/ Tel. P.-Erosion Total $ // �% Cert No. ,-. 1).? ) `"y e SBD-5823(R.10/99) INSPECTOR