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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 /> Pob(cck; Kvem CArr. Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,Oily,State,Zip) Deed Restriction;CSM <br /> 5 2 5 In u-1-1,‘ 116Th S i-retz+- t J e3f d 11 h 3 , w. 53214 Variance(# ) <br /> on PHONE ELL eHONE E-MAIL ADDRESS <br /> iy 416-9130 ,`)(4)391- el h3 2/Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Po64ock j ' Sums ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (1 S4v+1N iolh Si-reei-- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Wesf Ails , W . 53211{ <br /> PHONE Pp ONE , Site Plan approval from <br /> ON) 453 -4010 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Li EI@VatlOn of property <br /> ❑ NUMBER OS$/Ogi 1^334'9137-3 C —I 6.WI frontage drawn to scale. <br /> TOWNSHIP: SECTION: _ <br /> SUh Pr%tri t- 33 '/4: S% '/1/<: S 1ij ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 473'0 Co,i A- 1- u.K..1 T T Sun 1 r4iWric- t S 3S-c10 ❑ Sanitary permits <br /> CSM: LOT 'SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION " <br /> V <br /> PROJECT DESCRIPTION: g1eCHaA�( <br /> 11,154-cM net,J s 1.h o CxiS+r ► lon 2$b <br /> .c._ a a s , <br /> . ❑This project is a new building or structure. 1 , <br /> ❑This project is an addition/alteration to an existing building or structure. _ l ' :3 � Y <br /> SANITARY SERVICE: PERMIT NUMBER: I a° <br /> zM <br /> ❑SEWER ❑SEPTIC fe " :a # "' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) "": .". <br /> AREA TO NEAREST SQUARE FOOT: r <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) • t� C� <br /> t e <br /> BASEMENT: 1ST FLOOR: Y S a•es a a a <br /> n4 TOTAL SQUARE FOOTAGE: , :z <br /> 2ND FLOOR: 3RD FLOOR: "" � r <br /> vie _ Ivey <br /> aESTIMATED CONSTRUCTION COST: 33 00� . �� >V8C t <br /> , v x p, <br /> 5(Please round to nearest dollar) � <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 NiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ®Yes LI 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) 0Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes (XXT No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> 545-112(4108) <br />