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SUPPLEMENT to Web-App# <br /> BONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION . _ CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 't' 8(IN) a I L•LI ( ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,Stale,Zip) <br /> Deed Restriction;CSM <br /> 5405 --EX1.G-ro(J DR, ORE-Got , W( 5351 5 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION;;` and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ei-tIk s rr ILLG'R- co.. T- `L-c- E ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3igto kiNm�y Rp, <br /> (City,sate,zp) (City,State,Zip) ❑ Setbacks <br /> rcyrr-AGE G2-c1€1 L.)1 . <br /> PHONE 5 35 277 PHONE ❑ Site Plan approval from <br /> 6A-58"-2s3(0-11a Ca Cec 1 faa£s—87'7—/3 applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ../1 As.rn;Ito rC�571.5j-t'c-c.5 GE:0-e■D tYx�i •Cor' <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpa/accessdane.co.cianewi.usn ❑ Elevation of property PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P perty <br /> ❑ r,,, o3�/oS/z•.-3zz-9/do-0 �) 3 Fr-mks <br /> frontage drawn to scale. <br /> TOWNSHIP: 1 C71 ❑ Driveway r i 1,3 A 1/: 1i�i: ypermits <br /> ADDRESS: <br /> (state,county,town) • <br /> 1 Z`1 Z lJ- ME91,J A R42'. ❑ Sanitary permits <br /> LOT SUBDIVISION BLOCIQLOT (public,private) <br /> / 3853 <br /> • -0.OSED PROJECT INFORM•TION r "4 =v- -,-_� <br /> PROJECT DESCRIPTION: = i r '• <br /> S-F 2 <br /> This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER <br /> ' r-.� <br /> ❑SEWER SEPTIC 1 <br /> HEIGHT IN FEET:4. NUMBER OF STORIES: (Not including basement) <br /> r <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , t , ` h 1 <br /> BASEMENT - 1ST FLOOR: <br /> 2 040 3 3o0,00 j TOTAL SQUARE FOOTAGE 4, ; ---: . < 'r - <br /> MD FLOOR: 3RD FLOOR <br /> 5;340-00 <br /> ' Fnt rl <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "- '- '' -- `- .P 300,ana -eo - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes )3(No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes )KNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? XYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes larNo <br /> es this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> Ws a location survey required? (see reverse) ❑Yes rlo ❑Don' ow(7. Is this to correct a violation? ❑Yes o ,'Don't `' <br /> -BASC ,YZ Ha-ur r' Rw - 210443 <br /> Qir1Ct4- 1 cl z <br /> .2,o-c0 yf {rza.-- cTccrP APPLICATION MUST BE SIGNED <br /> G� c <br /> I 01-1 (Continue on Back) -► -I► -► <br /> ses112 luoel 31300 3f> <br />