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ZONIN e ' ERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAMtE 1 <br /> CSI1° 1 grf44 �d `Ct-- ❑ Zoning Status; CUP; <br /> OWNERADDR (Number,Street,City,State,Zip) <br /> g ) Deed Restriction; CSM <br /> Co• T,}ry dr Sun Te-x.p.G c.,5 j. 5' X O Variance(# ) <br /> HOME PHONE CELL HONE E-MAIL ADDRESS <br /> y26- i53-0.1A2 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> -P.c..)- > rnr-S By rhGf s 4o C4.4- rv,#fa+,, 41-c-- ❑ Site Plan including location <br /> AGENT ADDRE- CO TRACTOR ADDRESS of well/septic <br /> SA,1 6 S S 3 S& 54; <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> w - • , c,), .3557 c.)44.1 u c.rt s3S 7 <br /> PHONE PHONE El Site Plan approval from <br /> (cva-- r ` - 7 4 7g Got- 2)-7-7C 7g applicable township. <br /> E-MAIL ADDRES. E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LCICATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT 4 ACREAG <br /> ❑ PARCEL P?//_ Zce4° 95 l 646...c, frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> l6' a 1 1/: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state, county,town) <br /> 2 a : • CerL) % Jr St: PAL <br /> CSM: LOT SUBDIVISION BLOCK/LOT 1=1 Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION 40STAFf ft- <br /> PROJECTDESCi ION:1k c15-1.d-4. Uz.m is= ,, , <br /> ❑This prof-c is a new building or structure. <br /> Putted U6;0 <br /> This proj-c is an addition/alteration to an existing building or structure. <br /> SERV PERMIT NUMBER: ural[ • <br /> S: ER SEPTIC rf (a= ';:=';('":1': $ <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> b ' '1 0.-,:,;,:„i„..-.. •..� <br /> (Ai', <br /> a , �� am, <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shor (a � , t) r_ <br /> (Outside dime sins including unfinished area, attached garages and above grade decks or porches) �A � <br /> BASEMENT: 1ST FLOOR: j t! S3t� 11 � <br /> 4, TOTAL SQUARE FOOTAGE: ��r,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: q: \ <br /> CI " Lotion Sur <br /> ESTIMATED I O STRUCTION COST: r - bl <br /> —► ♦ ♦ ♦ ♦ ♦ �at1d 2411000 ,k'' '-`: ' <br /> .,its <br /> (Please round to nearest dollar) /�costs, , <br /> 1. The prope y is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EjNo ❑Don't know <br /> 2. Is there a e land or floodplain on or near the property? ❑Yes ❑No �� Don't know <br /> 3. Have you t:I•ed with the township about your project and are they in agreement? ,Yes ❑No <br /> 4. Has there .,e-n a zoning permit issued for this property in the past 5 years? ❑Yes JS1No <br /> 5. Is this proj:ct associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a locatio •urvey required? (see reverse) ❑Yes allo ❑Don't know <br /> 7. Is this to c.rr-ct a violation? ❑Yes 2 No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />