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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Brian Happ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 343 Ruth Drive, Jefferson, WI 53549 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Michael F. Simon Builders, Inc. Michael F. Simon Builders, Inc. LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 817 South Division Street 817 South Division Street <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Waunakee, WI 53597 Waunakee, WI 53597 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 608-849-5916 608-849-5916 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> td @simonbuilds.com td @simonbuilds.com ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usl) CI Elevation of ro e <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> ❑ PAR frontage drawn to scale. <br /> NUMCEL R BE 0708-092-2589-0 A-1 0.918 <br /> TOWNSHIP: SECTION: <br /> Middleton 09 1/<: NW 1/a'/a: NW ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 4515 Deering Trail, Middleton, WI 53562 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 9 Fieldstone Estates (public,private) <br /> PROPOSED PROJECT INFORMATION hPROJECT DESCRIPTION: Y <br /> Deck addition � �st!nc 11, ''I <br /> . ❑This project is a new building or structure. Li Permitter .Ise? i <br /> ti This project is an addition/alteration to an existing building or structure. = i;:SANITARY SERVICE: PERMIT NUMBER: 0 uralAd ire▪sS y,, <br /> ❑SEWER ❑SEPTIC fIt, exis )5 , <br /> HEIGHT IN FEET: t NUMBER OF STORIES: (Not including basement) <br /> ° <br /> iq' <br /> la r 0d01)I. a SIr1C <br /> ' h riIa d + .tn�ent) <br /> AREA TO NEAREST SQUARE FOOT: , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ErOsic 9Clr▪ttFOl permit <br /> 6 � , •TOTAL SQUARE FOOTAGE 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: ill tng/aCCess) <br /> 680 Review LA lion survey <br /> ESTIMATED CONSTRUCTION COST: Sri IV Ileb4e opts <br /> -► -► -► -� -► -► 'a,.' c <br /> (Please round to nearest dollar) � 10,000.00 � ��.� r'� � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> 6 u APPLICATION MUST BE SIGNED <br /> tt21aios> �� (Continue on Back) -0- -0. -o. <br /> sa5 <br /> '.i)- -;'/ . <br />