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I <br /> ZON G PERMIT APPLICATIO www.countyofdane.com SUPPLEMENT to Wab-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNERp E _ 1J /� <br /> �/t�`!► �L�. C�7.G� ❑Zoning Status; CUP; <br /> OWNER• DRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> gg / Cry ' 6", M1 / oii.e.8s, lv,t S`_35 7,) Variance(# ) <br /> HOME P • E CELL PHONE E-MAI ADDRESS <br /> -46 - 77, it E-sc r if 4 chi a hicrM.i .a,rip Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N M CON RACTOR NAME <br /> r 1 'D rowN E CoNs7/RcrcTip A) ❑Site Plan including location <br /> AGENT A•D"ESS CON RACTOR ADDRESS of well/septic <br /> / ' 0,2 ,'- ,N ST <br /> (City,Slat Z1 i) (City,•ate,Zip) ❑Setbacks <br /> l'orr jeleiNSS w,z- S7s.1� <br /> ❑Site Plan approval from <br /> PHONE P�E S - 7 7 _ t?3�,ir applicable township. <br /> E-MAIL AI DRESS E-MA LADDRESS <br /> c.- Re M 7-C .1. 7-DS, out 7- ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/haccessdane.co.dans.WLusl) ❑Elevation of property <br /> PAR PARCEL NUMBER 'ENT ZONING' ACREAGE. <br /> ❑PAR:: OS07-OP/"g8i/.f' i '7.7 t 7 frontage drawn to scale. <br /> TOWNSH ON. Li Driveway permits <br /> O S' ' t ' T4� 1�°�'�°' Rv7' (state, county,town) <br /> ADORES' <br /> ?S ' % C TY I/Wy 6, /1-7T: 7'O el, to 535?A ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJEC .:SCRIPTION: <br /> Li,/ ' go L elI Al rg? 0 A} . 7 / s-/Pe O F B� e ) ❑ Zoning District <br /> . OThi. •roject is a new building or structure. ❑ Permitted Use? <br /> ,,afhi. •roject is an addition/alteration to an exiting building or structure. <br /> SANITAR Si RVICE PER IT NUMBER ❑ Rural Address <br /> n1EWER r)EPTIC (new/existing) <br /> HEIGHT I F ET: NUM:ER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> Shoreland (attachment) <br /> AREA TO NEAREST S o UARE FOOT: <br /> (Outsid: d ensions including unfinished area, attache• garages and above grade decks or porches) ❑ ErosionControl permit <br /> BASEME T: 1ST FLOOR: es,disturbance, <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes, <br /> . filling/access) <br /> 2ND FLO.R: 3RD FLOOR: <br /> 3)00 5-"? FT ❑ Review Location Survey <br /> ESTIM'T:D CONSTRUCTION COST: ♦ ♦ ♦ ♦ ,,� �� UOO ,- and available options. <br /> (Pleas- ro nd to nearest dollar) <br /> 1. The .'r.perty is within 300 feet of a stream or 1000 feet from a pond or lake? ,Eyes ONo ❑Don't know <br /> 2. Is th:re a wetland or floodplain on or near the property? _Wes •1 o ❑Don't know <br /> 3. Haves you talked with the township about your project and are they in agreement? ❑Yes 0 o <br /> 4. Has I :re been a zoning permit issued for this property in the past 5 years? ❑Yes ao <br /> 5. Is thi• . oject associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a loc.:tion survey required? (see reverse) ❑Yes ita' o ❑Don't know <br /> 7. Is thi. t. correct a violation? []Yes P! o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -* <br /> 545-112(4/14) <br />