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; DATE TYPE NATURE OF WORK OWNER CONTRACTOR VALUATION �
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State of Wisconsin
Department of Industry, WISCONSIN UNIFORM ,��
Labor& Human Relations APPLICATION NO.
Division of Safety& Buildings BUILDING PERMIT D
Mad so69Wl 53707 APPLICATION -'�v r 7��1�
Wisconsin Statutes 101.63, 101.73 (See Instruction on back)
PARCEL NO.
PERMIT REQUESTED sTRUCTURE HVAC LEC ❑PLUMBING
Owner's Name Mailing Address Telephone
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Contractor's Name ; Mailing Address Telephone
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PROJECT LQCATION ,,, ��4,SECTION ,T rv, R, Elor)W
Building Address Subdivisi n Nam Lot No. Block No.
.�c'-� /� �S .5"'�2 84- �
Z nin District Lot Area � Front Rear Left Right
,�� �a� sq.ft. Setbacks �S� ft. ��.� ft. ��'� ft. � ft. €
1a PROJECT 3.TYPE 6. ELECTRICAL 9. HVAC EQUIPMENT 12. ENERGY SOURCE
ew ❑Addition ❑Raze ingle Family Entran�e Panel orced Air Furnace Fuel S ace Ht . Water Ht .
Alteration ❑Repair ❑Move Two Family Size:���� amp Radiant Baseboard or Panel
❑Other Se 1ce: LP Gas ❑ ❑
❑Other ❑Heat Pump Nat.Gas � �
nderground ❑goiler
Fuel Oil
Overhead ❑Central Air Conditioning Electric ❑ ❑
7b.GARAGE 4.COWST.TYPE 7. FOUNDATION ❑Other Wood ❑ ❑
❑Attached ❑Detached constructed oncrete 10.PLUMBING Solar ❑ ❑
Manufactured Masonry Se er Coal ❑ ❑
Z.AREA ❑Treated Wood �unicipal Other ;
�j 5.STORiES �Other Septic 13. HEAT LOSS (Caiculated) `
- Basements d Sq.ft. �
Permit No.
' /-� v�/ 1-Story $, �J$E Envelope BTU/HR i
Living Area 8 0 Sq.ft. 2-Story ❑Seasonal 11.WATER Infiltration BTU/HR
�Other
ermanent
Garage ''�2�'� Sq.ft. � ❑Private-on-site We�� 14. ESTIMATED COST
Other �unicipal Utility ���x� ,
$ V !
t
The applicani 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, n the Department or Municipality; and certifies that all the above information is
accurate.
SIGNATURE OF APPLICANT DATE �
CONDITIONS OF APPROVAL This permit is issued pursuant to the following conditions. Failure to comply m y result in suspension or revoca-
tion of this permit or oiher penalty.
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�S'S'V�NG ❑TOWN CVILLAGE �ITY ❑COUNTY Municipality Number Municipality Number of Dwelling �
❑STAT- ❑INDEPEND Location, if different
JURISDICTIQN oF: ��2�czf� � !� ��� _
FEES: PERM1TiS) WIS.UNfFORM PERMIT PERMIT 1SSUED BY:
ISSUED SEAL NO.
Plan Review . . . . . . .$ Construction
VAC NAME �
Inspection . . . . . . . .$ �^ lectricai �f
Wis.Permit Sealls) . . .$.�i� Plumbing DATE ! —�� � ��
Other. . . . . . . . . . .$ ❑Other � /v¢
CERT. NO. ��� `
TOTAL. . . . . . .$ :t
'�ILHRSBD 5823(R. 11/84) WHITE — Issuing Jurisdiction YELLOW— DILHR GREEN— Inspector PINK—Owner/Agent