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STATE OF WISCONSIN
DEPARTMENT OF INDUSTRr, LIBOR ANO
NUMAN REUTIONS
Drv1sIDNOPEACTrANOeuuDlNas
~i~ INaTONAVE.
WISCONSIN STATUES /Ot A]
""°I'°"~W'~~"°'
WISCONSIN UNIFORM
BUILDING PERMIT
APPLICATION
PERMIT NO. ~
PARCEL NO.
~~
PERMIT REQUESTED ^CONST ^HVAC ^ELEC LOMB
Owner' m Mailing Address Telephone
'Dt_
Con ra 's Na a Mailing Addre Telephone
~~ 7~
PROJECT LOCATION ~~< v., SECTION , T N, R E(or-W
Building Address , Subdivision Name Lot No. Block No.
Zoning District Lot Area
sq.ft.
Setbacks Front
ft. Rear
ft. Left
ft. Right
ft.
1. PROJECT 2. TYPE 3. ELECTRICAL 4. HVAC EQUIPMENT 5. ENERGY S OURCES
Entrance Panel ^ Forced Air Furnace Fuel
w ^Addition Ingle family Size: AMP
Alteration UTwo family ^Radiant Baseboard or Panel
^Garage ^Other Service ^ Heat pump LP Gas
^ Underground
^Attached ^Boiler Nat. Gas
^ Overhead Fuel Oil
^ Detached ^ Central Air Cond ~° water
Htp. Htg.
O
^ ^
.
^Other 6. CONST.TYPE 7. FOUNDATION ^Other Elec.
^ ^
Wood
^Master plan no. ^ ite const. ^Concrete $. PLUMBING Solar
(if applicable) anufactured ^Masonry Coal
outside ^Treated Wood Sewer
9. AREA p;,Mff1Oe 10. STORIES Other
^Other unicipal ^ ^
^ ^
^ ^
^Basement sq.ft. ,~`~-Story 11. USE Septic
U2-Story ^Permit No. 12. WATER
^ Living Area sq•ft• ^ Other easonal
ermanent ^ Private
^Garage sq.ft. Other unicipal
e applicant agrees to comply with the Wisconsin Uniform Dwelling Code and other Municipal Ordinances and with the conditions of this permit; un erstan s
that the issuance of the permit creates no legal liability, express or implied, on the Department or Municipality; and certifies that all the above information
is accurate.
,~J p
SIGNATURE OF APPLICANT /rte=:~. /~~, ~; c DATE
CONDITIONS OF APPROVAL This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or
revocation of this permit or other penalty.
13. ISSUING JURIS ICTION ^VILLAGE TY ^TOWN ^COUNTY ^STATE
NAME ~ MUNIC. NO. ~ ~/
FEES PERMITIS) WIS. UNIFORM PERMIT
ISSUED SEAL NO.IS) pERM1T ISS B
PLAN REVIEW $ ^CONST
INSPECTION
WIS. PERMIT SEALIS) a~
OTHER ( 1
TOTAL $ .
^HVAC
^ELEC
LUMB
NAME
DATE ~~}
CERT NO.-_ ~9~/
U I L H Fi -SB D-5823
ISSUING JURISDICTION/AGENCY