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SUPPLEMENT to Web-App # <br /> ONIVG PERMIT APPLICATION wuwvcountylofdane.00m <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Jo n Parr i' I' ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �l Deed Restriction;CSM <br /> 93Z t c)c,s/e y Rd Ord 9b� 1.O 53 5 '7s Variance(# ) <br /> HOME PHONE CELL HONE E-MAIL DDRESS <br /> 608- :,4 Z'08'6 (o8-83"90`/c ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C hat Ai pi i of /lad,San Sfe v .SID 1ftr— ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5321 I/oj.es Rd Satre <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> fri4C , on t4. 537/8 5q"Ai e- <br /> PHONE PHONE ❑Site Plan approval from <br /> 603 838 G./60 S4 d, applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> S 5 Act er- , , etc 6,4m,c o , U Floor plans to scale <br /> .,,,1 <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL q frontage drawn to scale. <br /> NUMBER 0507_X53-Z$OO.4O ( - I <br /> TOWNSHIP: SECTION: <br /> °r e.]or) '/a: 1/41/4: ❑Driveway permits <br /> ADDRESS: J p (state,county,town) <br /> q.5 Z- W e S le y r1 1 ❑Sanitary permits ' <br /> CSM: LOT s/h SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION P� <br /> �..�� S�' ''l:V EW <br /> PROJECT DESCRIPTION: .` <br /> Qu;Id S Sept So v-) rop.r7 U Zoning Dis <br /> • ❑This project is a new building or structure. <br /> CI.Permitted se? ,�� <br /> RThis project is an addition/alteration to an existing building or structure. Z� 1 <br /> SANITARY SERVICE: PERMIT NUMBER: U Rura . "reSS " <br /> EWER r)EPTIC (new!XiSting �� <br /> HEIGHT IN FEET: y NUMBER OF STORIES: (Not including basement) t,,.t r <br /> /a ' / U we!drill./:. slain <br /> IShorel 1e t y <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) E ,;= <br /> BASEMENT: 1ST FLOOR: Q VY -LU i It <br /> a Z 5 I TOTAL SQUARE FOOTAGE: I S O eS •I • z0 <br /> lling/a. ss . <br /> 2ND FLOOR: 3RD FLOOR: ,,,,;-,;, .-f., : <br /> .v sk 'v`I <br /> ..- o ey <br /> ESTIMATED CONSTRUCTION COST: Q p ., . ■.,0'g <br /> (Please round to nearest dollar) $ 36 f , , _. .1 S. <br /> A (fit 3$ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Olo Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Des Do Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? E Yes EVo <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 FA o ODon't know <br /> 7. Is this to correct a violation? ❑Yes « o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) = = = <br />