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ZONING PERMIT APPLICATION www.countyofdane.com Y e.com <br /> SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 3-0 & >t✓ 1'L'1 F/25-T5/r, ❑Zoning S to UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed s M <br /> 3 9-- 0 2 70 6 l92,5`7-411---'5'e' RO /1�,/76 7)If/i C- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ‘a - 57 93 ❑Site Plan dr w o scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and include dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan clu g location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/sew <br /> (City,State,Zip) (City,State,Zip) ❑Setbtieg <br /> PHONE PHONE ❑Site Plan :,/ ..,z, om <br /> applicabl- s, - <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plan9 toscale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusl) El Elevation fVp perty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 03Y-4806/1 033 9.:<-2 2°l—q frontage d n to scale. <br /> TOWNSHIP: SECTION: <br /> • <br /> 1/4: 1/1/4: ❑Drive p m't r--- <br /> ADDRESS: (State, ) a. <br /> ❑Sani' itsA <br /> CSM: LOT SUBDIVISION BLOCK/LOT i'(.U! <br /> (pub e <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: '/ <br /> 't �`r Cr' eiin f(?) .2tc(5 f ,ex '❑ Zoning ria <br /> ❑This project is a new building or structure. �/ tTPermiti' Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER C EPTIC (new/exs try <br /> HEIGHT IN FEET: VV "�1 / NUMBER OF STORIES: (Not including basement) �'.—:J <br /> ❑ Wetland/Fl r-•J lain/ <br /> r Shorela r r-': ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: r---1 Er0510 rol permit <br /> 33 6 4, TOTAL SQUARE FOOTAGE: j (slope ante, <br /> (p filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ R���7tccI1LLt7�' ' -_ on Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ar i i'!v-il-•le options. <br /> (Please round to nearest dollar) ©QQ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IgNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? !'es ❑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 ao ['Don't know <br /> 7. Is this to correct a violation? [Yes jalo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) <br />