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6o. c3 0 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> I OW NAME <br /> I Ci't /iUL ❑ Zoning Statute UP; <br /> 77 A DRE (N er,Street,City,St te,Zip) <br /> g a 6-07 L N • }1 F ' (� , �� Deed R�strrt tion; CSM <br /> 7 I �J VarianceN(* ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn-to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE T NAME , CONTRACTOR NAME <br /> , 6H-A) b S'r1nt_0 n Site PI n in ding location <br /> AG NT ADDRESS -/.1 CONTRACTOR ADDRESS of well/s tic <br /> j 2_0 trio nr" OGU✓{r <br /> (Cty, tac, n �-r ni� (City,State,Zip) ❑ Se bat ks <br /> ,'T L �� ; III �, <br /> PHONE 2 3� 1 S PHONE El Site n royal from <br /> 66 U applic0� nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 5rel,/,0 Pl-,, . &-/.,-r/ d,4-, -^`(,ry k" ❑ Floor pftrfs to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CU RENTZ NING1 ACREAGE:PARCEL El NUMBER -CL- 23-7-1/ f'ly l' 1 (FXJ 3 J b D frontage to scale. <br /> TOWN IP: SEC ION: <br /> cV l )LrtS(I 2-3 %: 1/4,4. ❑ Drivew y e its <br /> ADDRESS: (State y, own) <br /> CSM: LOT SUBDIVISION BLOCK/LOT (publ v is <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTIOt <br /> L1\)4VK1 1\06M -C(..KVEA) ?') r .0-fit- OPT-VD/kJ ❑ Zoni g District <br /> ❑This project is a new building or structure. ❑ Perm t d Use? <br /> gThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addr sss <br /> FISEWER SEPTIC (new/exi In <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> Wetland/,��Floppd��a..i�nl <br /> Shorela i attadhment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOIOf2' ) ' I-1 ErosionCtontrol permit <br /> 1 `i 1 TOTAL SQUARE FOOTAGE: 1 (sl0 P e 1 nce, <br /> filling/ c s) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Li Revi r Survey <br /> ESTIMATED CONSTRUCTION COST: $ I 0 14 and a ai4 e ptions. <br /> 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 lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? n Yes ,No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? C Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes eNo <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 n Don't know <br /> 7. Is this to correct a violation? ❑Yes L8No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ■ - <br /> 545-112(4/08) <br />