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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 'Pp 1-4-P <br /> d-4'�'l.LA C I El Zoning Status;CUP; <br /> , <br /> OWNER ADDRESS (Numb Street,City,State,Zip) Pte,' r Deed Restriction; CSM <br /> �� L V L �p l7 MD 5 I / J CR kf P1' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS/ / <br /> TO(iLA) •�r,� « G-// AL Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME '/' <br /> AtCt f � P fiy, fl 4 S DCI 14-c 1. S .( J4i6 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Lm--/ cOt.n Grp s 6 101,6? cut-0CA) 5T <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> r2 I) a � W ( r- 1c3 n4-0 'SaU wt s3Z 1 <br /> ❑ Site Plan approval from <br /> PHONE � PHONE y applicable township. <br /> 1' - 3 ((•�'- 7 r c cO3'9 j r- 7677 pP p. <br /> E-MAIL ADDRESS E-MAILADD- SS <br /> R`C.4 Q (4o JEt e 5 f , /NF Woo S&wRl( I�TC <br /> ,c Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/). ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER 67d -1(54 i ADO -e TO i CC)) Wt. frontage drawn to scale. <br /> TOWNSHIP: SECTION: ❑ Driveway permits <br /> V Ann MT 14' %%' (state,county,town) <br /> ADDRESS: 6 LuG r'a� SOS JFR./ n1-kCr Lme 3 ❑ Sanitary permits <br /> —CSM: LOT SUBDIVISI N �3 BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF i EVI J `; <br /> PROJECT DESCRIPTION: ` t- <br /> EX r UP -PRO k) -t- PTly Pof� ®nmgDis,� <br /> . ❑This project is a new building or structure. <br /> This project is an addition/alteration to an existing building or structure. � ` ' <br /> SANITARY SERVICE: PERMIT NUMBER: "� ' o s - Y;kV'li•' <br /> d <br /> nSEWER (SEPTIC , �� . <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ''. ..7'w <br /> V �• �Vr.a-rc`hme t <br /> AREA TO NEAREST SQUARE FOOT: «-, -; , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: E7oSlL�n o[a t o e * <br /> 1-7), 5 e 4, TOTAL SQUARE FOOTAGE: 4 oe -.,_ - g „ <br /> ` n "A. '2'`g•• S.1' <br /> 2ND FLOOR: 3RD FLOOR: - , <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ ♦ $/ � a a 6 <br /> a o d <br /> (Please round to nearest dollar) o / r - <br /> r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [l to ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑✓No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I=1 No 1/' <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) ❑Yes ❑No Don't know <br /> 7. Is this to correct a violation? ❑Yes 12610 <br /> i , °i1 (1 APPLICATION MUST BE SIGNED <br /> U/ (Continue on Back) -► -4 -1 <br /> 545112(4/08) <br />