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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME \ ,� 1 (�n <br /> 3QL\S '5�n', l`c y\ �\ �TL \1 J i) ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1 I Deed Restriction;CSM <br /> S Vi VDAL AD - <br /> E`< RO 0 e -OCe`* W 2S- S S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> b•-1 135`b-`61)b5 ..)4(..1< —b-1®eV(...t) 446N'A:,-5 -C'P"' ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SAM•LS T1ERt\ `c ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> t\) 1 a o, l, HcPK\Nis RoAO <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> I\RL1 N(1\-01V kJ i 5 3G1 0 <br /> PHONE PHONE 1 ❑Site Plan approval from <br /> 6o%— 3 - \ 5 -1 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONIN ACREAGE:PARCEL 1=I Elevation of property El V p1� �lq q 1� Q "'1\�NUMBER <br /> a- \ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> V i-EN)N A S E v: S E %1/4: -7 ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> S ,D,o cLA3A VALL-(,`< RofP0 (\UN ik KEE W 1 5S57 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> IyO6\a I <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: € <br /> This project is a new building or structure. - �� <br /> ❑This project is an addition/alteration to an existing building or structure. 3 r <br /> f _ ,' <br /> SANITARY SERVICE: PERMIT NUMBER: ,.'''"3-: � <br /> ,•EWER ■.EPTIC 1 i''o� o — — 00 4 1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) r _ �# <br /> W s <br /> AREA TO NEAREST SQUARE FOOT: , <br /> �ws- . `, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' �.- , �` <br /> BASEMENT: 1ST FLOOR: ^ <br /> a av 3 a y`AC\ + TOTAL SQUARE FOOTAGE: 4, n as ��yA <br /> ;. <br /> 2Ns-ftoeR: 4VRI\(r-E. 3RD FLOOR: , <br /> ESTIMATED CONSTRUCTION COST <br /> (Please round to nearest dollar) -4 -+ -+ - -+ $ 3s 0 0 „ 4 Y_ y <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres Do ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? , Yes Eo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ilo '0671 <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) Elves Elo ['Don't know <br /> 7. Is this to correct a violation? Dyes alo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />