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i7T,. (7. 0 <br /> ZON1G PERNIFT a PP ■CAI1ON wwwcountyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> Ala)? I) `I"KIs-4 K- 'v( M l/ <br /> VT'YS o,7 0 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> (p$oi SIrtccfi Li; Verv✓ra LU/ 5'3973 Variance Restriction; CSM <br /> // Variance(# ) <br /> HOME PHONE CELL PI4ONE ,E-MAIL ADDRESS <br /> 608— v-t5-013$ 6g-1,95-(33(0 kr/sQ /ta/versonj',o r '11 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT NAME jJ <br /> wk &- / ^ogrr <br /> �c ui �i n9..S - Z;e5 Ve r- .! Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 405 W 4kr kci P6 BoX 3% <br /> (City,State,Zip) (City,State,Zip) p(Setbacks <br /> Mat nianl e, cOl 5-350 <br /> PHONE PHONE titiSite Plan approval from <br /> 6,o8 -3z15--(538'"/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 1Qoyer: Zi e91-e r ' L"'�'kht-t/di r9S,C'O J Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ['NU BER o(a a/o L a-3 53-4110-o R/4-3 g,g(05 outage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -T0 G9 iv?0 cE 35 1/: A.16 %/<: S►) Driveway permits <br /> ADDRESS: tate,county, n) <br /> (/30/ Sunset hr; 'Verov- (N/ 53573 <br /> CSM:)�� /^ LOT t ^ , SUBDIVISION BLOCK/LOT ❑`S- It-r*t er \ / _ <br /> 10 J/ (.1,b. ,�t rivet ) J� <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / i'6t/ <br /> IPos+framc bwrldin5 on 6054-wail`launderho✓1 14 gravel drivewa1(/I7') LI zoning D riot <br /> - This project is a new building or structure. ❑ Permliv Use? <br /> ['This project is an addition/alteration to an existing building or structure. �V/ <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER r)EPTIC (new/e sstt�fi ) <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> 1t0 YVL 9-r ❑ W-tla ••dplain/ <br /> �^^�/ ' - • ;- - • (attac a i.-• <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> B <br /> all <br /> ASEMENT: 1ST FLOOR: EroSIOnControl permit <br /> TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: / --/a 51 • 'eview o ti 4 Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -► -► -► ♦ _► $ �j J) Q I and av/ .. ,-'•ns. <br /> (Please round to nearest dollar) b / ( / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes a o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aes U' o <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 ao ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ,lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ <br /> 545-112(4/08) <br />