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State of Wisconsin
Department of Industry, WISCONSIN UNIFORM (4308
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.
- - -- ' A� ' ". s 4' ` (.STRUCTURE I.HVAC ALEC ❑P
er LUMBING
Own' . , e Mailing Address Telephone
Contr.ctor's • ame Mailing Address Telephone
ff
% ' /e, SECTION , T N, R, E(or)W
Bui 'ny Adddress Subdiv' n Name Lot N Block No.
4,� / " 5 ' / c,i / i�,4�sr -
Zonin • istrict t Lot Area /
t of Front f Rear / Left - Right
iCi • Sq. ft. Setbacks ft. 4 IP
ft S ft. • ft.
VI ew ❑Addition � mgle Fa En tran c e Panel Forced Air Furnace F uel S pace Htg Water Htg.
II Alteration ❑Repair 0Two Family Size: / /J � amp Radiant Baseboard or Panel LP Gas ❑ ❑
Garage ORaze ❑Other Service: ❑Heat Pump Nat. Gas fg
A ttached ❑Move ❑Underground ❑Boiler Fuel Oil D ❑
Detached ❑Foundation ❑Overhead ❑Central Air Conditioning Electric ❑ ❑
❑Master plan no , , s , ❑Other a Wood ❑ ❑
Of applicable)
❑Site constructed oncrete Solar ❑ ❑
Manufactured U Sewer Coal ❑ ❑
.- ( ❑Treated Wood iitIMunicipal Other
Basements /T. 5 Sq f t .
`fl` . ,. ❑Other ❑Septic % Al �, �
" � Permit No
1 -Story Envelope BTU /HR
Living Area s,
9 ( Sq. ft. 2 Story ❑Seasonal � In BTU /HR
❑Other
Garage Other ermanent 4r T .D
9 Sq. ft _Private-on -site Well
Municipal Utility $ .2..5" doe?
The applicant agrees to comply with the Wisconsin Uniform 0 "g Code and other Muncipal Ordinances and with the conditions of this permit; understands
that the issuance of the permit creates no legal Iiability�.* - ss or i • •lied . • • - _ •• •.artment or Municipality; and certifies that all th ove i formation is
accurate.
SIGNATURE OF APPLICANT DATE /./. 1...f
CONDITIONS OF APPROVAL This permit is issued pursuant to the following conditions. Failure to comply may result in suspension or revoca-
tion of this permit or other penalty.
❑VILLAGE CITY ❑TOWN ❑COUNTY ❑STATE e'. 67 'fr f # '''''':e4//,, : x ,, 4 ^ NA _ j
* � �., . lJa1 a ( MUN NO. ..
FEES: a , '47' ' " v —
Plan Review $ OF onstruction
VAC NAME ' " w....
Inspection
fr
$ lectrical
Wis. " Permit Seals) , S -975—
9 () ` Plumbing DATE /f / — e3
Other $ / ❑Other / 9 „_ TOTAL $ WO f J 9 4 C ERT. NO. 3S z - / o 4
DILHRSBD 5823 (R - 1/82) WHITE — Issuing Jurisdiction YELLOW— DILHR GREEN — Inspector PINK — Owner /Agent
INSPECTION REPORT
FILE : DATE : v !
1
RE: 4
FOOTING SLAB BACKFILL STRUCTURE INSULATION OCCUPANCY
OTHER T
VIOLATIONS /REHARKS:
7. ") (/ / b"-lo/7),
•
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DATE /7 74 3
NAME ,41 , (1 , , , a411. ' ADDRESS -Z7( < ��1�:
LOT
/' BLOCK WARD Aa
SUBDIV. ZONE
STREET NO.674?)4/ ,A,Z1 LOT DIMENSIONS
SIDEWALK EXISTING YES [::: NO Ple
BUILDING GRADE ELEVATIONS STAKES SET AT SITE
`8 , 19 g`?) BY K P.a
/ /Al
FEE: $2.00
r
DE ARTMENT OF PUBLIC WORKS
Al inilli°
I, the undersigned, owner or agent of the above descrie,Jpr.pert .• ee to have the
grade established before excavation has commenced.
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