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2\ <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME __ ___ <br /> Marx °E J°`AA o& d 4-.{- ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction;CSM <br /> (q1()1 t IQa4 CcrifasAL Grow '1(11 535 2 7 Variance(# ) <br /> HOME PHONE CELL PHONE E4AIL ADDRESS _ ,� <br /> -II Z^ 4647 7l2`444g bokit( J.C�ct-k-Ilc•e.,6 IJ i/te Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION an includes dimensions <br /> AGENT NAME CONTR ACTOR NAME <br /> 'Kick A rbb-Le- fid.i'P CA•rtfAvt,et;a(t Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> VV000'7 tia,r,12oickwauIce, 5� <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> 1'ekOk Lu ow Ku5395.E <br /> PHONE PHONE Ii.: e Plan approval from <br /> (603.) 54;c7-. 1(-7 ' applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT P E1( UM ■. URRENTZONII � ACREAG _ Elevation of property <br /> ❑ PARCEL ��I � j ( 22 frontage drawn to scale. <br /> NUMBER �(JJ ll -I,i Li <br /> TOWNSHIP: SECTION: <br /> _ ,/: ,/4,/: ❑ Driveway permits <br /> ADDRESS: ` (22 (state,county,town) <br /> ��� �� �� ❑ Sanitary permits f <br /> CSM. LOT SUBDIVISION BLOCK/LOT ry p <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ryt 4 <br /> PROJECT DESCRIPTION: �� "" F } �, 3 : ;1 <br /> ,IM This project is a new b (ding or str ure. 1, <br /> ❑This project is an addition/alteration to an existing building or structure. dt i m ,:,, € .-Y <br /> SANITARY SERVICE: PERMIT NUMBER: '-- 9 1-,--..,?:'',-.4m 4,:4h.rN.- <br /> ❑SEWER SEPTIC Z II � .�+L i . <br /> ��- <br /> HEI T IN F ET: ' NUMBER OF STORIES: (Not including basement) � � ' " �� <br /> A. - 2-4 -r � , 'r y e t ,/� <br /> ,tit , Rb�1 "- :v •a L <br /> AREA TO NEAREST SQUARE FOOT: 7x ,: .- � <br /> (Quickie dimensions including unfinished area,attach( rages and above grade decks or porches) ` w '-iiii t IA <br /> BASEMENT: ...OZ 1ST FLOOR: •--f-lV Aas' ® � � <br /> ffi ' 3t q1 i'\'` 4, TOTAL SQUARE FOOTAGE: ): 3, - ri � ,„ i <br /> �fl'0C) Y _ T g <br /> Z ��� a ' <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: 7 . ��� <br /> (Please round to nearest dollar) ♦ ♦ "� "♦ ♦ $ 4 g1n69 fi7:s <br /> 500" <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake. ❑Yes 0 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 12 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? laYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 1No <br /> 5. Is this project associated with a rezone/CUP/varian e p Ition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) jeD EYes ❑No ❑Don't know <br /> � <br /> 7. Is this to correct a violation? ❑Yes 1LSJ No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />