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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME f
<br /> qJa w1 /G b �•e roe ! �el .
<br /> OWNERADDRESS (Num Street,Cit ,State,Zip) • ❑ Zoning Status;CUP;
<br /> 91‘�� a All f/ �� e)j` , �� 5- f-.5 Deed Restriction; CSM
<br /> ... ✓a S Variance(# )
<br /> HOME PHO E ELL PHOt4 E-MAIL ADDRESS
<br /> 600-35'7-771.2 ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT E /� CONT T9R NAME
<br /> AGENT Pe.ct-- £ i► led,ilosepe ❑ Site Plan including location
<br /> AGENT ADDRESS /� CONT TOR AD ESS �y of well/septic
<br /> 02020 I asa)o s 6b,b R ra d� 1�0,2.QD
<br /> (City,Sta, Zzip) (City,State�,Zip) ID Setbacks
<br /> ∎Va l�, *, r"L 4,lb/9 ve PB10a, 4-21^ ,J. l,,f
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> A6 27o'D3a y� 4� �yf?7 applicable township.
<br /> E-MAIL DRESS E-MA�I DDRE S i
<br /> 60 i c1ea, ht.II dj ,,,. . �ZG..� 'ci ci ha.IAa , ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property
<br /> PARENT PARCEL NUMBER: CUR N ZONING: ACREAGE:
<br /> t� ? :f '�—� frontage drawn to scale.
<br /> ❑ NUMBER D/�!'.�,�� s.�/'D
<br /> TOWNSHIP: SECTION:
<br /> "731,a u�0IGsvn 1/4: 1/41/4: ❑ Driveway permits
<br /> ADDRESS: j /4/// �� (state,county,town)
<br /> 1//y e./.L4 co , ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION lir STAF RISE
<br /> PROJECT DESCRIPTION: � A '
<br /> ❑This project is a new building or structure. N
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITAR SERVICE: PERMIT NUMBER: Rural ++rea
<br /> SEWER SEPTIC 8 .t 4
<br /> Tie 1 f "'
<br /> HEIGHT IN FEET: / �� NUMBER OF STORIES: (Not including basement)
<br /> i
<br /> /5 3 U ., tz...•lainj
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> ,$horelsa •
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> BASEMENT: 1ST FLOOR: t #real,• it",`
<br /> , /zo ab• _ 4. TOTAL SQUARE FOOTAGE: 4, i =••-z,d,...71.,,,,,,,:7 DCe,,
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> ESTIMATED CONSTRUCTION COST:
<br /> (Please round to nearest dollar) "♦ ♦ '♦ ♦ ♦ "♦ a
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [ "o ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? [2'5'es ❑ o
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes [✓jNo
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank none)
<br /> 6. Is a location survey required? (see reverse) DYes ❑Don't know
<br /> 7. Is this to correct a violation? El Yes 2No
<br /> \L I 1 l SD APPLICATION MUST BE SIGNED
<br /> 545-112(4/08)
<br /> (Continue on Back) ■ -♦
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