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fill <br /> L <br /> G PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> ,PERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> • ER NAME , ,^ <br /> 611 el All n-e Lb c� Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) r ��, Deed Restriction; CSM <br /> 321 2- DUX {,{d� �l�k'" `•P.� �-� ( �J JCJ' J Variance(#104-V1 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRE S <br /> ',05-514'36 12- l the 5a 61115b.co m in Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions • <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <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 /> re,„ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dano.wi.usn Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG : oP P y <br /> QPARCEL V t-4 -°10% /� frontage drawn to scale. <br /> NUMBER ON 7.-7 ✓' �� �� 4� g <br /> TOWNSHIP: SECT! N: <br /> AI IIZOU.mr,A___ %: 1/4%: 2 Driveway permits <br /> ADDRESS: (state,county,town) <br /> cliuek,' Lax)e_.- `e).i--1 [Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> t-4.15-2A.,4 e-- ❑ Zoning District <br /> g) <br /> This project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER JEPTIC PO-.24i6 - 66515- (new/existing) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> -2:22 Z ❑ Wetland/Floodplain/ 1 <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Z— o ❑ ErosionControl permit <br /> 13 13 Li D ' n61 r �L j TOTAL SQUARREE FOOTa�E: j (slopes,disturbance, <br /> `D ca--� ` , T - Z filling/access) <br /> 2ND FLOOR: <br /> �� � 3RD FLOOR: ^ i <br /> 2 4• dt ❑ Review Location Survey <br /> ESTIMATED CON RUCTION COST: and available o dons. <br /> (Please round to nearest dollar) -' ♦ ♦ -► "� $ l V0 DOD, OD P <br /> Lilo, IS <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes D o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes oy" o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,Yes I o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes 'lo <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) Elves fro o ['Don't know 1 <br /> 7. Is this to correct a violation? QYes V,, o 1,.. <br /> Ni x - 0377 � <br /> �3 ; <br /> I 'll(/' ( `��. ©O "` " APPLICATION SIGNED <br /> (Continue Back) -► -► -D <br /> 545-112(4108) r <br />