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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App it <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME pp 1 - <br /> � C --"S0 c5 I o NBC ik. ping Status; CUP; <br /> /OWNER ADDRES umber,Street,Citkl State, ) ( toi,) N Deed Restriction; CSM <br /> Ven L % �,wdpri 0 ccbl,,cc Wr J sv Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRE <br /> • ^i Z 19 a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAM CONTRACTOR NAME <br /> 15e t- 10-21A-P-Sa,r1.9 0 Site I including location <br /> AGENT ADDRESS L CONTRACTOR ADDRESS of I eptic <br /> 11 A0 <br /> ity,St Zip) (City,State,Zip) etbacks <br /> ouiz�w to <br /> Q Site PI approval from <br /> PHONE 0 r $73—8'2'/ PHONE f, ,,15--- ap • a e township. <br /> E-MAILADDRES EMAIL ADDRESS q;f7.4t5-d <br /> r plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dlane.w➢.usl) El to operty <br /> 0 PARCEL PARENT PARCEL NUMBER: �/ CURNTZONIN�G: ACREAGE: front e d wn to scale. <br /> NUMBER (IS I) - 01 4 1°Jd11"'Q 1\` / 10// • <br /> TOWNSHIS SECTION: <br /> 1 OW h of p 1/4: 1/41/4: ❑Drive - =-rmits <br /> (st- -, "'Linty,town) <br /> ADDRES % C / j 10 J °l. <br /> CY��}�(/- �^� ,J El CSM: •ermits <br /> CSM: LOT SUBDIVISION —BLOCK/LOT S _• IC, .Irate) <br /> n 1lr�c�u/cotY E.57" $ <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ,,rr�� L <br /> OecL rep/trek •- (A 0),_, ing District <br /> . DThis project is a new building or structure. P miffed Use? <br /> Rrhis project is an addition/alteration to an existing building or structure. <br /> j <br /> SANITARY SERVICE: PERMIT NUMB : ❑ Rural A.••..---._ . <br /> EWER _REPTIC 1\/ ri (new existing) <br /> EIGHT I iFEET: <br /> V IG zjJiTof -/-id)/( A,+ NUMBER O STORIES: (Not including basement) <br /> ]— 62/4ACh ho km-- <br /> Wet - .r dplain/ <br /> horela ttachm <br /> en <br /> TO NEAREST SQUARE FOOT: <br /> 4 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Erosio o rol permit <br /> BASEMENT: 1ST FLOOR: z. 9 (slopes • urbance, <br /> j, TOTAL SQUARE FOOTAGE: , ( P <br /> fillip• :cces <br /> 2ND FLOOR: 3RD FLOOR: <br /> i /� k11I ■ Review ation Survey <br /> ESTIMATED CONSTRUCTION COST: --► --∎ ♦ ♦ ♦ ♦ $ -006 •.,.-E•+0� and av le options <br /> (Please round to nearest dollar) d > <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? MI es 8lo ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes gflo DDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Wes QNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes Fo <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) DYes [No ['Don't know <br /> 7. Is this to correct a violation? QYes ElNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />