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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> bWNER NAME <br /> IC.NA EL . i-iebESK ( ❑ Zoning Status;CUP; <br /> OWN RADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 309? &4 TLETbp4 CIZOSSINcr Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3i8-007(0 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0412-Y—c3 RJ a&L DS Al tu ATE-t d.oKST ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS <br /> of well/septic <br /> 7779 S-FarofPS4 -4rai I 01774 94 re-re, - 4r - . <br /> (City,State,rj (City,State�jip) ❑ Setbacks <br /> Sty VeN t tit VI C )1 5355 O 5v+1 Treti r i ,P, 100 1 5355'0 <br /> PHONE t PHONE ❑ Site Plan approval from <br /> be $ ;141'4.44!1.3 blue 4qq-1.1163 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 PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: ` SECTION: <br /> $r/SM /. 1/1/. ❑ Driveway permits <br /> ADDRESS: �/ (state,county,town) <br /> 3 C.099 day+1_ loll rOSSM Sanitary <br /> CSM: LOT Ni_i BLOCK/LOT permits <br /> 2(1 W ) f, E5/ <br /> (public ,private) <br /> PROPOSED PROJECT INFORMATION t <br /> PROJECT DESCRIPTION: . , s„ ,._., „, <br /> (,A-2AGE ADD rtio>J <br /> W , � 3 � . <br /> ❑This project is a new building or structure. 1 ... 4 . <br /> XThis project is an addition/alteration to an existing building or structure. a <br /> SANITARY SERVICE: PERMIT NUMBER: 4.1 i,: °4r 1. :" i � <br /> ❑SEWER SEPTIC '' 4 ` i' a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � ` <br /> 1 y`''cif '_ * <br /> AREA TO NEAREST SQUARE FOOT: , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) . $ <br /> BASEMENT: 1ST FLOOR: ° �� <br /> 4, TOTAL SQUARE FOOTAGE: 4 -m �3 ,# �, <br /> 2ND FLOOR: 3RD FLOOR: )� e'.'.' s i " § <br /> L K)5, ic-� ':'t ^'° i' a � x x <br /> ESTIMATED CONSTRUCTION COST: [[ �� �� <br /> OpU �4 4 eas, e`� <br /> (Please round to nearest dollar) —∎ "♦ ♦ '♦ ♦ ♦ $ Z 3,, v v <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 ❑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 /> APCAUST BE ED— <br /> (Continue PLI on TION BacMk) B. SIGN—► ► <br /> 545-112(4/08) <br />