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ZONIN e ' ERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU TOMER TO PROVIDE <br /> OWNER NAME <br /> �N4 4, F54_1„,ele_ Ess e t2• <br /> OWNER ADDR:s (Number,Street,City,State,Zip) Zoning Status;CUP; <br /> c,),-1P6 1°✓` ►r>J ►^os e C ( r Deed ceesiction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ( ) <br /> ,DB (P'{ ' Gob a�(o /3(0: ►� QSwecA.,e Ck1-S*• CCo+i Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 3 et w,es Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> ,.,18 1.9 S Po.0 �os'e G f r <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE���a Wt El Site Plan approval from <br /> (00S 01101 13(0'1) lic9blttownship. <br /> E-MAILADDRE T E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi•us/) Elevation of property <br /> 171 PARENT PARCEL0N�MBE` �y� CCURR JTZONIN I ACREAGE: P t y <br /> PARCEL y y . frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SEC ON,:/ N C <br /> '` �j '/a: /` � 1/a1/a: N ^ ❑ Drivewa rmits <br /> vvv <br /> � <br /> )(sta ,county,town <br /> ADDRESS: av4/ C° r t kk C)`-Ce ❑ Sanita privramtet)s <br /> CSM: 1 I LOT t SUBDIVISION BLOCK/LOT .0 ,' <br /> PROPOSED PROJECT INFORMATION REVIEW <br /> PRQ J TIDE •) O 'r' '• <br /> q❑This prof-• is a new building or structure. h ' `Use. 'q- ecks 6 0, 6 c"c__ .,■ <br /> E This proj-c is an addition/alteration to an existing building or structure. <br /> SANITARYSER C:: PERMIT NUMBER: 1 0 RUIN ' <br /> r' v •! <br /> S:WER SEPTIC '�� ' <br /> HEIGHT IN FEE NUMBER OF STORIES: (Not including basement) <br /> __ --- 1( 1 rr t 0: as.s .11/-,;* <br /> a ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimens ins including unfinished area, attached garages and above grade decks or porches) "yj s <br /> BASEMENT: 1ST FLOOR: i� a a <br /> �—, x J a zic 4, TOTAL SQUARE FOOTAGE: ,l a e a a e 2ND FLOOR: 3RD FLOOR: Y/� ,4 1 4„). /`J, $ tea ci �� <br /> + IIC�Survey <br /> ESTIMATED CONSTRUCTION COST: $ s a -•4'''.:('''-r , p�rlS <br /> (Please rounc t• nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ /�� 660 ,; <br /> 1. The propel 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 we land or flood lain on or near the property? ❑Yes t No ❑Don't know <br /> 3. Have you fal ed with the township about your project and are they in agreement? [► Yes ❑No <br /> 4. Has there D--n a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this projec associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location •urvey required? (see reverse) ❑Yes <br /> 1-.P.go ❑Don't know <br /> 7. Is this to cor -ct a violation? ❑Yes Q1 o <br /> APPLICATION MUST BE SIGNED <br /> � (Continue on Back) <br /> 545-112(4/08) <br />