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LV1NG PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> ' PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> "'" OWNER NAME <br /> I - - ��///1-1:42.e; ❑ Zoning Status; CUP; <br /> OWNER ADDRESS Number,Street,City, fate,Zip) /� !� y�/� <br /> askLef,,,t ?i`f,...e 'G� 5.35 a 1 Deed Restriction; CSM <br /> 5 3/ Variance(# ) <br /> HOME PHONE , PHONE E-MAIL ADDRESS <br /> 33 5-776 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGA eL m /4 c N CONTRACTOR NAME <br /> /<e , Q�.,d / IV C ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 33161'm _ s'r <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> A/AC"kt' —/..ed4 '/ S3s9 <br /> PHONE PHONE 70 Site Plan approval from <br /> gw5"0-‘`$ 6 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ////�� <br /> $T!V' �,kkQrIu//1X,l� -crifl Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NPARCEL BER 07 o�/9�_73�0-D frontage drawn to scale. <br /> UM <br /> TOWN�SH,I/P� SECTION <br /> /// 1/4. 1/41/4. ❑ Driveway permits <br /> ADDRE/ss( y,, (state,county,town) <br /> 31-,t is ❑ Sanitary permits <br /> CSM: LOT SUBDIVISI'N BLOCK/LOT <br /> S p (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> i <br /> PROJECT DESCRIPTION: / , i;'i b <br /> A ���,� 0 I * 1 <br /> -a� <br /> //' lax <br /> . his project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: cc ;tdl'sss <br /> nSEWER EPTIC A as £ <br /> HEIGHT IN FEET: f NUMBER OF STORIES: (Not including basement) j z, <br /> AREA TO NEAREST SQUARE FOOT: * B <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) oaf <br /> BASEMENT: 1ST FLOOR: * � C � <br /> / 30 G 33 ri 5 4, TOTAL SQUARE FOOTAGE: 4, iii.* * Tban , <br /> J J CJ �� k�#BCS <br /> 2ND FLOOR: 3RD FLOOR: ���, <br /> /a$'� . <br /> ESTIMATED CONSTRUCTION COST: $ O O c_ ©y R available **s* <br /> (Please round to nearest dollar) ►Q ,1�,. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes Et% ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes ❑No Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ['Yes P o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dyes E Pdo <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) Dyes ENO gDon't know <br /> 7. Is this to correct a violation? ❑Yes ON <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -i <br /> 545-112(4/08) <br />