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ai" t 6 ! ' `.' <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / e ) <br /> �)� G'Yl Cj4 /J� S V l a V1 / e r <br /> ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Z7`S ? AAGCCY ���d Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDR S <br /> dog?/CI 7t-170_ .6C v The" cig0 647 oti„or,-comp Site Plan dr wn scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes d' ensions <br /> AGENT NAME CONTRACTOR NAME <br /> J c C'u . es ED kc, n• C Site Plan i9,cluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/ tic <br /> (City,State,Zip) (City,State,Zip) ❑ etb ks <br /> PHONE PHONE ❑Site Plan gppF rom <br /> applicabl t s ip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plank tq Icale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation pf�'operty <br /> PARENT �(PARRCELNUMBER: ( CURR TZONIINNG: ACREAGE: <br /> NUMBER W I f^/ 7/" ( g`, " t L-... Y 6 0 b ,ontage drFlWn to sc. e. . <br /> TOWNSHIP: f� J C SEC IQN: q - -" • t <br /> i,/ct 4)Y'1 1 1 1/<: t►V G. 1/41/4:N �� Iv Driveway permits fleP� <br /> (state, count <br /> ADDRESS: �� � kg:- <br /> Y,town) -Seti41)-- pc, <br /> — . Sanitary. mits I , <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub ' • II e � <br /> v �� <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DES('RIPTION: <br /> 3d✓'x S&4 / -'O/C.. M/! l01).. <br /> ❑ Zoning Dt ct <br /> •`gThis project is a new building or structure. 201 -o 1 93 [) permute u <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> 9 9 <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER r)EPTIC (new/exii ), <br /> HEIGHT IN FEET: ;ei,r` fr { NUMBER OF STORIES: (Not including basement) <br /> VD ❑ Wetland/ , . . <br /> Shorelan t -: meet) <br /> EA 0 NEAREST SQUARE FOOT: <br /> (Outside dimensions including un ' ed area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STFLOf�R• 7 ❑ ErosionC•It •Ipe• It. /' <br /> /� Za 4, TOTAL SQUARE FOOTAGE: 4, (Slope /'t t -nce, :- �/ <br /> filling/ -s ) <br /> 2ND FLOOR: 3RD FLOOR: /6' 2,;() ° <br /> pfd <br /> ❑ Review'Location rye <br /> ESTIMATED CONSTRUCTION COST: _+ b 0 and a .! <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 ,No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes OVo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <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 11411No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> EL e�e (�J7'I f Z�� <br /> APPLICATION MUST BE SIGNED 4 • 7/, r�1 (Continue on Back) -■ -► -► <br /> 545-112 /112(4/OS) ,J <br />