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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1v X.. A Tl)RSS-0 , L�cIA E. TWIN CI Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 126 5EAci+ AvE £' a Th W l 535f+ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608- i - 040 608- 332 -2O7; -or ben 2Q rn sn. c o M ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SArhE. AS 0wkw.. SAME As oW •ER, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> 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: CI EI2VatlOn of property <br /> ❑ NUM ER 0S12.-361 -0799-5 R-3 .20 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> AlgloN 3b 1/4: NsF ,/4,/: N1✓ ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 12.6 BEM* AVE., UCyfRToIQ, ' , 5353+ <br /> CSM: giGw ooOp EsrAreg LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> i sT AVOITnni 9 3 <br /> PROPOSED PROJECT INFORMATION EW H <br /> PROJECT DESCRIPTION: t <br /> 0 rt <br /> ADP Vit0 22' X(b i. a I V u. <br /> . CI This project is a new building or structure. n- Y <br /> I This project is an addition/alteration to an existing building or structure. - <br /> SANITARY SERVICE: PERMIT NUMBER: . - s <br /> SEWER ❑SEPTIC a ) ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' <br /> F 0 ® f Wit+ § r "rye <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 /> 352 4, TOTAL SQUARE FOOTAGE: 4, S. Vie_s,, „ m , <br /> 2ND FLOOR: 3RD FLOOR: <br /> — 352 i <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ s�. ,q--7:t: $ � , ,t.:1 <br /> (Please round to nearest dollar) {000•QD '.4''''''` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No a Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No II 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 Si No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► —► <br />