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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE NAME <br /> K%c,V. 4 - kmcstsV1 ing Status; CUP; <br /> OWNER ADDRESS (Number,Street.City,State,Zip) Deed Restriction; CSM <br /> X 5118 IV et-s or ou ik t -o,n ' 5-33'85 Variance(# ) <br /> HOME PHONE CELL PHONE •'t-MAIL ADDRESS <br /> 401-S7ff 3133 WI S 7S-3133 aSitE Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State, ) 11-Setbacks <br /> PHONE PHONE ❑Site n proval from <br /> appli township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS \ <br /> or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) E ation of <br /> PARENT PARCEL NUMBER: CUR ENTZOONING:: ACREAGE: property <br /> NUMBER 0 4(l -1 gi- 9701 —V A - 1 ( C�1 q. ( rontage drawn to scale. <br /> TOWNSHIP: SECTION. <br /> 113W V1 of 1Q� S k 8 '/4: 5eoFAr1/4�/4: ❑Drive ermits <br /> Q "� (s ,c unty,town) <br /> ADDRESS: <br /> :25 3 \ c C C 0 Q Sanitary p-rmits <br /> CSM: ^^ LOT SUBDIVISION BLOCK/LOT (pubi.�, •rivate) <br /> PROPOSED PROJECT INFORMATION A REVIEW <br /> PROJECT DESCRIPTION /� / <br /> (/�f J`_x/L' idc 2,4 13f ; ew.,.. �.q d n'ing District <br /> This ro ect is a new buildin or structure. <br /> project building rrn fitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE PERMIT NUMBER: ❑ Rural Address <br /> EWEREPTIC (nevkr <br /> HEIGHT IN FEET: �� NUMBER OF STORIES: (Not including basement) <br /> ❑ UV-1- d1P10•'•lain/ <br /> AREA TO NEAREST SQUARE FOOT: Shor • (attachment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ErOaianCOntrol • It <br /> BASEMENT 1ST'1 4 O ( 1 4, TOTAL SQUARE FOOTAGE: + (slopes • "U r'- <br /> 2ND FLOOR 3RD FLOOR: fiNtng/a T' <br /> 0 Q ❑ Revi w cati0 urvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ -7 o and av • options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 1:21No ['Don't kn'i3w <br /> 2. Is there a wetland or floodplain on or near the property? DYes ENo QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? DYes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes IZNo <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) ❑Yes a)o ['Don't know <br /> 7. Is this to correct a violation? QYes WIRo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —I► -4 <br /> 545-112(4/08) <br />