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I NG PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> rY" PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> ,.' OWNER NAME ,,•• `` <br /> w0-"04.S Ckha• Ck �C hk1Z_ ❑ Zoning Status;CUP; <br /> O R ADDRESS (Number,Street,City,State Zip) <br /> I8l I 6 r M■ It ., Or Lq C , (4)-r �) 3 S"7.7 Variiiance(#notion;CSM <br /> A1�D ( ) <br /> HOME PHONE �,C,ELLL PHONE E-MAIL RESS <br /> • , 1.... tov8 .S-dg IC A 0 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION j CONTRACTOR INFORMATION and includes dimensions <br /> 1NT NAME 1 '1 CONTRACTOR NAME <br /> 14 Maln�jc.`, Ii' AI rrti� 3 '�- ❑ Site Plan including location <br /> AGEtJT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3YC rf16cr <br /> (City,State,Zp) (City,State,Zip) ❑ Setbacks <br /> I`A ;s,,, , wz , 0-3.7 I 1 <br /> PHONE PHONE ❑ Site Plan approval from <br /> &O f-a-)9 -533 L/ applicable township. <br /> E-MAIL ADDRESS 11 E-MAIL ADDRESS <br /> K Ica.r er.e....,-.\V 1.® q.Y1o0, e O M LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL �-u. I. ^4 frontage drawn to scale. <br /> NUMBER DA/0610 1)4-4910' d <br /> TOWNSHIP: SECTION: ❑ Driveway'/4: '/a'/a: y permits <br /> �nt� (state,county,town) <br /> ADDRESS: <br /> I DR U ` I SemAk • .,'\ �a` ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ` (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PRO ECT DESCRIPTION: 1 ` <br /> NtuJ CDNskTt,.t,�114 . S■ r.�,t �4me'�� \ 1'N0rw.k. ❑ Zoning District <br /> . ]S(This project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUM R: ❑ Rural Address <br /> :I <br /> ❑SEWER V SEPTIC 5/5c G 3 (new/existing) <br /> HEIGHT IN FEE NUMBER OF STORIES: (Not including basement) <br /> x•11 1 ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR' ZDX"l LI ErosionControl permit <br /> 16/ 4 �� { , TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: V�D 1 3RD FLOOR: 1 <br /> filling/access) <br /> 48 q8, 00 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ �oo 00o. a b <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ai Yes ❑No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? gYes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes NiNo <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) LI Yes i4No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> 6 <br /> � � <br /> \ APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ ■ -► <br /> 545-112(4/08) ...\ <br /> z.Z '' '<'.,,, <br /> t q __, <br />