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ZONING '' ERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> JA \/ /q 11(° t' r)e' Cc / ❑ Zoning Status;CUP; <br /> OWNER AD6REoS (Number,Street,City,State,Zi <br /> HO2'7 r✓��J[/4d ii v I , re),,, �� 5 3 S)f 3 Deed Restriction; CSM <br /> E PHONE CELL PHONE E-MAIL / Variance(# ) <br /> 6Ac'-Sr 01•; / c r TSe(° / @ 4440, EL 4''`1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A ENT NAME ONTRACTOR NA <br /> .P g-0 S �e-lc (R / L},°-V ❑ Site Plan including location <br /> AGENT ADDRESS C TRACT R ADDRESS of well/septic <br /> co oX IV <br /> (City,State,Zip) (state,Zip) .) _i • ,��3 ❑ Setbacks <br /> e k u t �/ <br /> PHONE PHONE C / ❑ Site Plan approval from <br /> LP D 0 - 473 - 7 3g3 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ...t) .:;4 E'c • e (44 a( /ve ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZO ACREAGE: <br /> / frontage drawn to scale. <br /> ❑ NUMBER C3g/6-708 -3.23-5' -T. .'" r —1 1/ �5� <br /> TOWNSHIP: " ` SECTION: <br /> r{{ (," 1 %IA: ❑ Driveway permits <br /> I c� (state,county,town) <br /> ADDRESS: " <br /> I L. `r f/'( - ❑ Sanitary permits <br /> CSM: LO SUBDIVISION _ BLOCK/LOT <br /> (public,private) <br /> U C'c,c(r�S.�ti q0 j <br /> PROPOSED PROJECT INFORMATION +, �+ � <br /> PROJE T DESC RI i ION: > el " <br /> ‘e c 1 0„� g District <br /> This roe• is a new building or structure. �, <br /> Va Thi s proje• is an addition/alteration to an existing building or structure. <br /> NITARY SERVIC:: PERMIT NUMBER: Address <br /> nS:WER ,yipEPTIC (new/t is�l <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) vv,:, ,�,, <br /> IF - // 0 f ,,, , i i A 3 i ni <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimens ons including unfinished area, attached garages and above grade decks or porches) trot ” ��.y: F <br /> BASEMENT: 1ST FLOOR: <br /> 4, TOTAL SQUARE FOOTAGE: 4, ( .3a t '. a -Fire: <br /> 2ND FLOOR: 3RD FLOOR: � ;7 , <br /> ESTIMATED CONSTRUCTION COST: ! 2 ,. i or / pmt«; o(( s.` . <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ / LG„�✓6 F:" , ._ <br /> 1. The propelt is within 300 feet of a stream or 1000 feet from a pond or lake? ►3►es ❑No ❑Don't know <br /> 2. Is there a w=tland or floodplain on or near the property? II Yes '$No ❑Don't know <br /> 3. Have you tat ed with the township about your project and are they in agreement? ❑Yes ❑ o <br /> 4. Has there b-en a zoning permit issued for this property in the past 5 years? `❑Yes o <br /> 5. Is this proje associated with a rezone/CUP/variance(petition/appeal# ) (leave blan • :none) <br /> 6. Is a location-urvey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to cpr ect a violation? ❑Yes 0 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ -p <br /> 545-112(4/08) <br /> I <br />