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State of Wisconsin
Department of Industry, WISCONSIN UNIFORM
Labor & Human Relations
Division of Safety & Buildings BUILDING PERMIT APPLICATION NO.
Box 7969
Madison, WI 53707 APPLICATION
Wisconsin Statutes 101.63, 101.73 (See Instruction on back)
PARCEL NO.
�'
x m g YSTRUCTURE I "HVAC ELEC ❑PLUMBING
Ow : 's Name Mailing Address Telephone
/ 0.445 iusek( -. 0 - sr'Moot2 a .."3 / - /3s
Contractor's Name Mailing Address Telephone
i
' 'A, SECTION , T N, R, _Elor)W
Building Address Subdiv• ion Name Lot No. Block No.
4-0 `��4 Sr . / C)C1 -e ,41 ST 4-9
Zoni %District rot Area Front Rear Left Right p
1' 1 (3 (00 ./ Sq. ft. Setbacks ,7-5-' 7/ 7 C — f 6 O
ft ft ft, ft.
t " c - s «`. i 1 :_ 46 tout ., . . ' . Gv s
New ❑Addition Single Family Entraru a Panel �orced Air Furnace Fuel Space Htq. Water Htg. •
❑Alteration ❑Repair Two Family Size: /,'b amp LJ Radiant Baseboard or Panel LP Gas ❑ ❑
❑Garage DRaze ❑Other Service: ❑ Heat Pump Nat. Gas a
❑Attached ❑Move Underground ❑Boiler Fuel Oil M ❑
❑Detached Foundation (Overhead
❑Central Air Conditioning Electric ❑ ❑
❑Master plan no. 83& 4, f' els 7 O AT �
, ❑Other Wood ❑ ❑
(/f app /scab /e) ❑Site constructed IConcrete ' Solar ❑ ❑
» • ,, I Manufactured Masonry Se er Coal ❑ ❑
'' , , p ❑Treated Wood unicipal Other
�! �® S ft. `
Basements ry . .. ,� ❑Other U �" Septic '�,A' �I� Via}
n / Permit No.
d` Di -Story 8. Envelope `� E BTU /HR
Living Area �" Sq. ft. 02 -Story ['sea it , Infiltration /�j4j.? BTU /HR
❑Other
Garage Sq. ft. Permanent ❑Private -on -site Well STVSr
Other �� Municipal Utility $g DQ�
The applicant agrees to comply with the Wisconsin Uniform Dwelling de a .ther u • •• ordinances and with the conditions of this permit; understands
that the issuance of the permit creates no legal liability, express moiled„ n the epar . or Municipality; and certifies that all the above information is
accurate.
SIGNATURE OF APPLICANT &« / «ee DATE /1 -1 ¢
CONDITIONS OF APPROVAL This permit is issued pursuant to the following con. i ' • 4s. Failure to comply may result in suspension or revoca-
tion of this permit or other penalty. -
❑VILLAGE piCITY ❑TOWN ❑COUNTY ESTATE
7 1 NAME r)Ski SA- MUNIC. NO. —7Q 7- 1_
'.'
FEES: ? ..a ga
Plan Review $ onstruction
VAC NAME / .
tin/
Inspection $ Electrical p�
Wis. Permit Sealls) ..,. $ 30 Plumbing DATE / — / 4--61 -
Oth $ DOther /X
TOTAL $ 30 d 9J—
- �
Y CERT. NO. — a ¢""
DILHRSBD 5823 (R -1/82) WHITE — Issuing Jurisdiction YELLOW — DILHR GREEN — Inspector PINK — Owner /Agent
DATE /1 -7-f3
NAME .GIiP ADDRESS ol-7 o
LOT "1 BLOCK —` WARD ,°
SUBDIV.,.eG ZONE v
STREET NO. ,7?jtii� LOT DIMENSIONS ✓
SIDEWALK EXISTING YES fl NO
BUILDING GRADE ELEVATIONS STAKES SET AT SITE / a ,19 -= BY Kt'
r
FEE: $2.00
"
DEPARTMENT OF PUBLIC WORKS
I, the undersigned, owner or agent of the above descri.- p'opert .•ree to have the
grade established before excavation has commenced. 10 .
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