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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION C -TOMER TO PROVIDE <br /> 0,1/05.14-NAME <br /> .. oe.1 A- n e_ht.h(c. g <br /> i Zoning Status; CUP;OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> M <br /> G c s t?J 7s' hi ` deb 4 -r• �7� <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6 b '13?,0 10 ; °75853,( ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite Plan including location <br /> AGENT ADDRES' CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) ' (City,State,Zip) DI Setbacks <br /> PHONE PHONE R approval from <br /> '',,applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> z <br /> I�ofns to scale• <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) ,4-. ENy <br /> PARENT PARCEL NUMBER: v ( CIIRRE/NTZONING: ACREAGE:. , � front Elevation o rty <br /> ❑ <br /> NUMBER O6c'- d��.?"4 ( gQ Y" • front wn t cafe. <br /> TOWNSHIP: ECTION: • <br /> Ta,,�8 f 4 '/a: S' IAIA: s ,,,Ef <br /> riveway permits <br /> ��'� pP� (state, nty, n) <br /> ADORES$:`i 54_ ../^ .,/ <br /> CSM:Gy(l�ol� �(J ILOTTC SUBDIVISION BLOCK/LOT ❑Sanitary, ermits <br /> publi , private) <br /> PROPOSED PROJECT INFORMATION REVIEW <br /> PROJECT DESf IPTION: n / ✓ �/�ke oi9,:.�i�l A-1 f ff•t ,bi j (c) 4 I JSTAFF <br /> ningDistrict <br /> . ❑T 's project is a new building or structure. rmitt se? <br /> his project is an addition/ Iteration to an existing building or str ture. <br /> SA ARY SERVICE: PERMIT NUMBER: ❑ Rural dre i <br /> FIEWER EPTIC (new xistin ) <br /> HEIGHT IN FEET: /(,9‘..._�(,9‘..._ NUMBER OF STORIES:(Not including basement) <br /> ❑ Wetland/FI dplain/ <br /> Shorela (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionContro ermit <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,dis ante, <br /> � filling/ac s) <br /> 2ND FLOOR: 3RD FLOOR: <br /> et„-11- /v-/�— 3 `� ❑ Review Location Survey 0 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ `� '1 and available options. <br /> (Please round to nearest dollar) o(,�D <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es �'►o •Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes j,,► •Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Efres 112 o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes v o <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) esN ❑Don't know <br /> 7. Is this to correct a violation? es Flo <br /> p ? , t�(' APPLICATION MUST BE SIGNED <br /> / I; (Continue on Back) ♦ ♦ -♦ <br /> 545-112(4/08) (((,,,---��� <br /> gee <br />