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. -.. <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> (,k05+ 1 i I( Rrck LL C C-MLI C5/C"0.5� Dc veK,k(' ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Nwrber,%el,City,State,Zip) <br /> 3L(8 t-Jcoct la Ctr 0.d LSO i L....� 537or�/ Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESsS� <br /> 608-576-Y8 25 g 54- ,Kds ?e x01.0.0. co 4--1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME NAME <br /> -1--,-„,....5 (..2,-,e tl a C—4- CI Site Plan including location <br /> AGENT ADDRESS I / CONTRACTOR ADDRESS of well/septic <br /> 398 G-10001 iah d CI.(--- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> /la c(' t...j. �3 741( <br /> PHO E PHONE CI Site Plan approval from <br /> C‘08, 5 76 '12 25 applicable township. <br /> E ADDRESS a E-MAILADDRESS <br /> S4-b�ds?€ loo. corY ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARCEL NUMBER: CURRENT ZONING: ACREAGE: p perty <br /> ❑ NUM ER coi 810-c�8(r-93 Yo--9 A_S I r' C2 ? App . 5 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> !„ LA.CkC- 50 vt-H. IA: WA: LI Driveway permits <br /> ADDRESS: (state,county,town) <br /> £i 3 20 Ho eik-tr Rot /'fad,'so,t J 5 3 ?C 41 <br /> CSM: LOT SUBDIVISION BLOCK/LOT CI (public, permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRI TION: <br /> ki re e_Aka“c.5e Hooe 10t3 e_ <br /> . 114 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 /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: t t <br /> 4 7, 1-1 x 22 . C + TOTAL SQUARE FOOTAGE: <br /> 2ND FLOOR: 3RD FLOOR: O <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ $ 1 COO — <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 0/No CI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes It No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Cr Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in pq,r w, ars? CI Yes QNo <br /> 5. Is this project associated with a rezone/CUP/vari /-ppeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ErYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ,Qw..2-.6...x.10 ErYes DI No <br /> f, �,, &�yj(1Ap�"'�a� APPLICATION MUST BE SIGNED <br /> 545.112(4108) DMe C41t;>T(g ' 111 t^x <br /> (Continue on Back) -► -► -► <br />