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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT tolNeb-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> /iAVOI 1 nin <br /> og Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State ip) / Deed Restriction; CSM <br /> 9.,S i� Ca vn4 t��^I Variance(# ) <br /> CELL ONE E- AIL HOME PHONE � � <br /> 14 —i/3- S07f (.01- ,,ii---1-/o—134y, • rAlds, I--•1 -n q • cvri A ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> U.\ NI V L ' e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> / (City,State,Zip) (City,State,Zip) FQ-4Dacks <br /> PHONE PHONE Q appli�ownshi from Site <br /> appli township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wLusl) evation of property <br /> PARENT PARCEL N MBER: CURREN ONING: 3 ACREAGE: <br /> ❑PARCEL 3 i��D�19��_1.3?-17e,04 �,! — 3 I� frontage drawn to scale. <br /> NUMBER 1 <br /> TOW SHIP: SECTION: <br /> /�`'� / 3 1/a: %1/a: S' ❑ Drive ,: •ermits <br /> �1w�'`�{'��e- (sta =, cmunty, town) <br /> VA.DaRESS: �/ /�j CJ/ ��5b 0 <br /> �' Co`� � (i /ti `"'rJ FE Sanit ermits j <br /> cSM: ' LOT SUBDIVISION BLOCK/LOT C, rivate ki,, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIP ION: <br /> 3 c y Li S onin District <br /> . ❑This project is a new building or structure. P rmitted Use? <br /> E This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMITNU ER: ❑ Rural ' ":� <br /> FEWER REPTIC (1 <br /> ' I Del. <br /> HEIGHT IN FEET NUMBER F S ORIES: (Not including basement) n _ j IOOd / 4( l <br /> P �)� 39 . -__.•� ( p ' ' $ <br /> � ' d (attac •�en <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimension including unfinished area, attached garages and above grade decks or porches) rOSlO 'Con of permit <br /> BASEMENT: 1ST F) T--:-S Q)-, j TOTAL SQUARE FOOTAGE: l (slopes =v turbanz <br /> t� <br /> fillip. acce s) <br /> 2ND FLOG . 3RD FLOOR: <br /> Q 7 -evie ■ oc- on Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> ♦ ♦ -0. -0. and ava `••le options. <br /> (Please round to nearest dollar) _ii:gi <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eyes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? jYes ENo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes fNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? nYes ❑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) EYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Dies No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► <br /> 545-112(4/0B) <br />