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Vi( (3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME [ , <br /> kct L.e�✓ i&t( Vl O C blhi de Tom- Sk-( ❑Zoning Status;CUP; <br /> OWNERADDR SS (Number,St ,City,State,Zip) I f Deed Restriction;CSM <br /> 4$�155� ►'hi -� �c.� Otll�7� tWC� �Z Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CAN�TRACTOR. AME if.. ❑Site Plan including location <br /> AGENT ADDRESS CONTRACT R ADDRESS I of well/septic <br /> 10 a 01; &f e.e <br /> (City,State,Zip) (Ci ,State,Zip) ❑Setbacks kir 5.3593 <br /> PHONE PHONE I ❑Site Plan approval from <br /> r;O Off- 816 -9 Po applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL �/ �y� .��/ y+2� O A ' 12 frontage drawn to scale. <br /> NUMBER �57/cf1O . -Iv'- CT <br /> TOWNSHIP: SECTION: <br /> p , 1/1/: ❑Driveway permits <br /> Ao�RESS: Sf rt I P /4 (state,county,town) <br /> $"8 7 1 SS�5cJ ilk ID r <br /> CSM: I^ LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> �( (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> i <br /> 3k^ <br /> PROJEC/TT DEESCJRII]P(T',IwON: - py ,, <br /> . ]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: 1 Address - <br /> 1EWER r)EPTIC <br /> HEIGHT IN FEE to, NUMBER OF STORIES: (Not including basement) =, in/ <br /> I ) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) y <br /> BASEMENT: 1ST FLOOR: <br /> 2(0°� j, TOTAL SQUARE FOOTAGE: , , <br /> #ll „,c,"3) <br /> 2ND FLOOR: 3RD FLOOR: 2(i7 O <br /> s <br /> 4a(i,..;-)rs survey' <br /> lease r ED CONSTRUCTION COST: • _ . $ l Ji ! 770 ions. <br /> Please round to nearest dollar $ `J`y <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes laio ®Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes �Vo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,]C Yes ao <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ONo <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 o ❑Don't know <br /> 7. Is this to correct a violation? Oyes No <br /> ACAIST BE SIG NE <br /> 545-112(4/08) No 41111 (Continue PPLIT on ON Back MU ) <br /> v <br />