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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION "STOMER TO PROVIDE
<br /> OWNER NAME
<br /> 5-r AIL--c s- M t r..1 t' A l•)a2--m Fs)G-TO1J
<br /> EA oning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) eed Restriction; CSM
<br /> 7 42 C 2Ea-nHa jE,vJ DR. CaTt4E G cza061 w' 535 Z'-7 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS •
<br /> (4008-7-20- iq t I ite Plan drawn to scale
<br /> AGENT INFORMATION I CONTRACTOR INFORMATION nd includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> ChR{s m 11-1-4•1C-. CaN , t.,LC- SAme ❑ ite Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 3181, ki,,ti c'
<br /> (City,State,Zip) (City,State,Zip) Setbacks
<br /> Cana CAE G eavE W i 535 z.'7 ❑
<br /> PHONE PHONE ite Plan a royal from
<br /> (018-2,047,—l t 6(0 ap•lica township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> et,nls r>7'UO<ce�.s{ry c.:r...,0-r■-- . i ;l.C.O-1''1r1 ' loor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> ❑ PARCEL ,IS 16111 -22.z-SSts - a S R- ‘ P, (.2¢c� rontage drawn to scale.
<br /> NUMBER
<br /> TOWNSHIP: SECTI•N: t_ �
<br /> t�a-r1.�a&E G t'_e . E Vv M Driveway permits
<br /> 1•••%•__ � .� 4 1�%:J\,ADDRESS: O (state,county,town)
<br /> WA Sanitary permits
<br /> CSM: LOT / SUB.VISION BLOCK/LOT
<br /> )33g O ( •ublic,private)
<br /> PROPOSED PROJECT INFORMATION ''' '',STAFF REVIEW
<br /> DESCRIPTION; 0,-,„
<br /> (Z— \N) ( Q c t e,,1\ y 0 cc_ ',i':,,..,',.',Ing Dist**,40 ,
<br /> . This project is a new building or structure.
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> ,y
<br /> SANITARY SERVICE: PERMIT NUMBER: 0
<br /> (SEWER SEPTIC (3- 2.015 — 00 I .ff-f'
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) e,
<br /> 23 ' L e, �,. .1 ,. 4
<br /> Sha'� ., e',
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) !.
<br /> BASEMENT 1ST FLOOR: Z ' c„` ,,
<br /> I^1 g' �C t,$ 4 TOTAL SQUARE FOOTAGE: j ' . 0,,6,',.../, ' • ° m
<br /> 2ND FLOOR: 3RD FLOOR: i , (CIQ `, f
<br /> ESTIMATED CONSTRUCTION COST: '' • c"11a lab e t t
<br /> ♦ ♦ ♦ ♦ ♦ ♦ $ �a� /
<br /> (Please round to nearest dollar) f„? ,, 7';
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑YesVo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 1Jo ['Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? i'es ❑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) El Yes IgNo ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes No
<br /> 41.,,z) ‘ i iR APPLICATION MUST BE SIGNED
<br /> (Continue on Back) ■ ■ ■
<br /> 545-112(4/08)
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