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A � 15 3- � oS SUPPLEMENT to Web-App#PERMIT APPLIC ION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> '14 I of KD -j e---s [2: Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street..City,State,Zip) Deed Restriction; CSM <br /> sq34) Cobs L)'dlc.,' L.,./ct00,: lcge, t.-Pt 5'35, -7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> - <br /> Gs7r-Zi 2-o77o 60 ,- -t VoB S4-eue Iredd O( .Co i✓t ' E'Site Plan drawn to scale <br /> AGENT INFORMATION f CONTRACTOR INFORMATION and includes imensions <br /> A T NAME ,/rtz,,� / CONTRACTOR NAME <br /> G eZG14iy +. 4,/i11 l'9 <br /> _.__. 504 C ©Site PIa eluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS ................_............._...................................._...._....................._..7 of well/septic <br /> (City.State,Zip) (City,State.Zip) ® acks <br /> eRev&)A )L3 5-3 Si$ 5 4 nn <br /> PHONE -___.. _.__._........._......._.___.._.___._._._. PHONE _. _........__..............____......... Site '1� <br /> ='royal from <br /> INS-170o appl' a. township. <br /> E-MAIL.ADDRESS E-MAIL ADDRESS '..`..a' <br /> /c V q — 1G-.�Floor plat scale <br /> PROPERTY/LOCATION INFORMATION (http:/taccessdane.ca.dane.wlus/) Elevation of ro rty <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE: p <br /> 0 PARCEL q ;q �} frontage dra toscale. <br /> NUMBER .2l+3 v / O 0O / U Pt ci ...ti <br /> TOWNSHIP: SEC IOM <br /> V X e v Ai A _ 1/: 1/41/4: El Driveway permits } ' �( <br /> ADDRESS ----.-- (state, county. town) r M1���L� <br /> L _.._..._.__._......_......................._.. ��.................... [Sanitary permits Acme <br /> GSM: LOT SUBDIVISION �BL OCKJLOT • (public, private) )r <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION <br /> 1 064,c4_0 `.j tI 1b 0 ZoniAttilsrntsiC fit- <br /> . EiThis project is a new building or structure. <br /> 0 1— <br /> PermitOd Use? �F�.� <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: I PERMIT NUMBER: A f L.] Rural Address <br /> DEWER TIC I �/ (new/e it ) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) (� <br /> le J f3, q ' �l �\ LI Wetly�l /¢ �lain/ <br /> _._. _._. - ShortlC +ti �Iktachment) <br /> h'2EATO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) -- <br /> _.......__..._.__._.._.._._....__....._._...._ ..........._ __-.---....._....._.__.____.-____...__.......__......_..... f� Eros'. .0 intro)permit <br /> BASEMENT: T15TFLOOR: <br /> i�: P <br /> r+� �a r { TOTAL SQUARE FOOTAGE: t (510±f- 'd I 1 rbance, <br /> t l3 .. .. f�a�-{ filling/ac -ss) <br /> 2ND FLOOR, 1 3RD FLOOR: <br /> 1 if Vt d CT R Fir tion Survey <br /> ESTIMATED CONSTRUCTION COST: -► --► -► j' ar l Ai ale options. <br /> (Please round to nearest dollar) d L.+C3.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? . DYes [Ds.lo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ['Yes No Q <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) QYes ©No ['Don't know <br /> 7. Is this to correct a violation? QYes [alo <br /> ... .(11) . APPLICATION MUST BE SIGNED <br /> 545-112(4108) I v� CDC(AAA A-CUA) i (Continue on Back) ♦ -► -■iclAkev.0• <br />