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,e' Go -,(2,. <br /> /,--'-- ) <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUS •MER TO PROVI <br /> OWNER NAME <br /> M t ch�c l S NI c,,r �«0d r/4-/ <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1 Deed Status; CUP, <br /> AA-) kc I Val Q.0 t'�C .. 5 �-1 Deed Restriction; CSM �� <br /> (,� CA� c`- �C"' {'y ' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Ats, ata -110-1 aq t. 6,..hoo Lc,m 0 Site Plan dra n to e <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes i nsions <br /> AGENT NAME CATRACTOR NAME <br /> r l►'m VI rmtc. Cor ruc can ), Q Site Plan ncluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/se tic <br /> 1.1-1-1-1 2- CA-i ►NI ��� <br /> (City,State,Zip) (City,State,Zip) Q Setb`t5( <br /> ►.1 e 63 C.2(ar t t,S VI t 5331`1 <br /> PHONE PHONE 0 Site Plan pr <br /> 605 J 13-1 U 1 e> applicab ip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> - ti.VICIL,06 ("(; • + • n e_f L/ Floor plan 6 Scale / " <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRE ZONING: ACREAGE: it''Elevation f pro <br /> ElPARCEL <br /> NUMBER `��V`�f D 9093521 C f �{ �� Z gq 0 frontage d to scale. <br /> TOWNSHIP: -'rte U4 koqE SECTION: <br /> Tom n O R V t t r- - 3 1-1 '/a: N l= %4'/4:Ki ISDrivew. pe <br /> ADDRESS: (state, ••. • ' o <br /> 5111 Cuba \lo--1 let Rd Qc,t.,,,v_k.e e v.i► 5 35i <br /> ►1 Sanitary •. i <br /> CSM: LOT SUBDIVISION BLOCK/LOT ,���, �p <br /> id 1 l� I — (public, i ril.- 7 (/l,i : <br /> PROPOSED PROJECT INFORMATION ;STAFF <br /> PROJECT DESCRIPTION: �� <br /> L-I-b` “410' de#c chec.I c\c,.ray-/5hcd 'zoning Diver r <br /> . This project is a new building or structu7e. ` <br /> /-t Permitted pie? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rural A.•1 <br /> - <br /> )EWER il$EPTIC (new/- j • ` <br /> HEIGHT IN FEET Z / NUMBER OF STORIES: (Not including basement) ' <br /> I ,'4 Wetland*,•••A. ,300 <br /> AREA TO NEAREST SQUARE FOOT: <br /> Short. ,'Pr'' ment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ErO8i�tCOntr01 it <br /> BASEMENT 1ST FLOOR: <br /> �D © j, TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: / e O <br /> filling/access 0 <br /> � <br /> / U U Re)" , I.*:�'' • " Ivey <br /> ESTIMATED CONSTRUCTION COST: ne <br /> (Please round to nearest dollar) <br /> ..... --► --► _o. -► -► 2. DQQ,00 and a ' .!>. _ ; • •ns. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes g]No QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes !I o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes ►: o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? QYes QNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) ►21 o QDon't know <br /> 7. Is this to correct a violation? es o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -+ <br /> 545-112(4/08) ) -4. <br />