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ZONING PERMIT APPLICATION wcountyofdane.com SUPPLEMENT to 111F 4b-App <br /> ww• <br /> PROPLh t ' I1WNEtt INFORMATION CUSTOMER TO PROVIDE <br /> 0m-_ <br /> r OWNER ADDRESS (Number.Str t C State Zip) ❑toning Status; <br /> 0 `* Deed Res is ' n: CSM <br /> Variance( _ ) <br /> HOME PHONE CELL PHONE E-MAIL ADORES <br /> (O0S Sti l le -k) owl e I l0.htio-tom ❑ <br /> ` `�h Site Plan d to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATIL ti and include dimensions <br /> AGE ME CONTRACTOR NAME <br /> ❑Site Plen incl ing location <br /> 'AGENT ADDRESS CONTRACTOR ADDRESS of well tee <br /> (City.State tpt (City,State.Zip) ❑S'tetl�bMptcs <br /> PHOIVE PHONE El Site vvV9-w., oval from <br /> ap r i• '=township. <br /> E-MAIL ADORIESS E-MAIL ADDRESS <br /> ❑Floor',VII scale <br /> PROPERTY/LOCATION INFORMATION (httptd/accossdano.co.dar,o.wl.us/; ❑�IeYatlo Of roperty <br /> PARENT PARCEL NUMI� CURRENT•. ING r '3 E: <br /> ❑PARCEL /O( . 3 ,/ ( vi N. frontage n to scale. <br /> NUMBER V <br /> TOWNSHIP: SECTION. <br /> T0\JY\ O Ore D9 Y\ Y4. Y.'/a: ❑Drive Its <br /> (sta� t town) <br /> ADDRESS: l <br /> i� k I l I ❑Sani ,4-∎i <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ;)10-Q. ' r! (Pub c, ' i . e) <br /> PROPOSED Rtto..P CT INFORMATION te . STAFF REVIEW <br /> AR• '. T DE� 'IPTION: <br /> 4 <br /> 4 . rcy14 P�,r C atoning t t <br /> . This project is a new building or structure. b Perriljtt Use? <br /> This projectis an addition/alteration to an existing building or structure. <br /> ITARY SERVICE: PERMIT NUMBER: Q•:Rural Address <br /> EWER )KIEPTIC (new/ ) <br /> HEIGHT IN FEET: + NUMBER OF STORIES: (Not Including basement) ❑ <br /> 2. <br /> AREA TO NEAREST SQUARE FOOT: 'i :�r hment) <br /> (Outside dimensions including unfinished area,attached garages and above wade decks or porches) <br /> BASEMENT 1ST-FLOOR: t r.i perrrllt <br /> 4 TOTAL SQUARE FOOTAGE: 4 ( . ,ltd , t • .nce, <br /> 2ND FLOOR: 3RD FLOOR: of ., ''" )- <br /> ESTIMATED CONSTRUCTION COST: . ii of .d- O• ;-i• —D. -40 r► "P '♦ W 2.0yr...../ <br /> Pease round to nearest dollar) <br /> C <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies &I o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes FA o EDon't know <br /> 3. Ha'e you talked with the township about your project and are they in agreement? ❑Yes Q o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Eklo <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) <br /> Ye-S <br /> [Yes s � o �on't know <br /> 7. Is this to correct a violation? ❑Yes r <br /> • <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Contintm on Beck) -P -P -P <br />