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State of Wisconsin
Department of Industry, WISCONSIN UNIFORM /5 3 '----
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.
*,,, ❑STRUCTURE ❑HVAC ❑ELEC ❑PLUMBING
,;.
9737004 ame Mailing Address Telephone
! Z 5 e- - / 210 i izleeT /Z, �/
C r's Name Mailing Address � � g A dd ss Telephone
'4 Y4, SECTION T N, R, E(or)W
Building Address S isi Nam
�� u Lot No. Block No.
Zon istrict Lot Area g
C./a.10 Fron / Rear i Left / Right
/7 6 ` Sq. ft. Setbacks 7/ ! 6)7J-' � `
`fib 6. ft. ft ft
I'I � x DAddition f \� S Single Family A _ y Ena e �. � a Y 3 i �� � m,' ... s ft � ® -',
Pa nel I; rced Air Furnace Fuel Space Htg. Water Htg.
■Alteration DRepair III Two Family Size:. 6 V Forced
amp • Radiant Baseboard or Panel LP Gas ❑ ❑
EGarage ❑Raze DOther Service: ❑ Heat Pump Nat. Gas
DAttached ❑Move I)nderground El Boiler Fuel Oil ❑ ❑
❑Detached ❑Foundation Overhead ❑Central Air Conditioning Electric ❑ ❑
DMaster plan no. , t A� ❑Other Wood ❑ ❑
(If applicable)
it constructed oncrete Solar ❑ ❑
M anufactured ❑Masonry Sewer Coal
Other
❑ ❑
I^ '- b ❑Treated Wood Municipal
❑Other 46,4A
Basements, '' Sq. ft. 7 S eptic .III
Permit No.
Living Areal Sq. ft. K2 -Story �. Envelope c�i`i;+ BTU /HR
DOther Mal 114' Infiltration// BTU /HR
Garage / '� Sq. ft. ermanent ❑private -on -site Well
Other �;
€-
Municipal Utility $ 55 0 — Z 7-0
The applicant agrees to comply with the Wisconsin Uniform Dwelling Code and other Muncipal Ordinances and with the conditions of this permit; understands
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.
SIGNATURE OF APPLICANT DATE 3 - -2_3 - ' -q -
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 C CITY ❑TOWN ❑COUNTY ❑STATE
. §NAME 05� r
MUNIC. NO
FEES: € 4 ° 't 7 : + ' —
q _ fi r.. -
Plan Review $ ,_ • onstruction �,,�
VAC NAM�.L '`L`7
Inspection $ Electrical ,/
Wis. Permit Seal(s) ..,. $ Plumbing DATE S o `-
Other $ ,, ❑Other J 4-',/ 4
TOTAL $ lf�4 r '
CERT. NO.
DILHRSBD 5823 (R_1/82) WHITE — Issuing Jurisdiction YELLOW — DILHR GREEN — Inspector PINK — Owner /Agent
DATE `ZZ - t'•
NAME (ok vseK ADDRESS
LOT 95 BLOCK WARD 1 —
SUBDI V. 115 E K E g- ZONE i2— /
STREET NO. ..- / e 92'4 --✓ L0 I MENS I O NS 6jC7'l ��
SIDEWALK EXISTING YES n NO.
BUILDING GRADE ELEVATIONS STAKES SET AT SITE 3 -2L^ , I 9 4 BYKNI
FEE: $2.00
DEPARTMENT OF PUBLIC WORKS
I, the undersigned, owner or agent of the above described property agree to have the '
grade established before excavation has commenced.
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INSPECTION REPORT
FILE :c 7'•/; DATE: 6" 7
RE e / t - <= cl /(v-z-c,-
FOOTING _SLAB _BACKFILL _STRUCTURE _INSULATION __OCCUPANCY
OTHER Al / 4,&AO •
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VIOLATIONS /REMARKS: F :ef„,„, --,,,,,,-
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