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ZONING PERMIT APPLICATION ww .countyofdane.conl SUPPLEMENT to Web-App # <br /> w <br /> PROPERTY OWNER INFORMATION CU.TOMER TO PROVIDE <br /> OWNER NAME <br /> ttre '&000 0 ning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> eed Restriction; CSM <br /> 7v2, ► is.. ttp ,t . Mr t6pIJ 1 t 53' t 3 Vari <br /> Ce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ( o -t•4?5S 1��1ks.lnn *o �IY141`• �tr'�'t S e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Mt CAA D i-- /VI04t$O t/JJ�4/2'6 — • e Plan including location <br /> AGENT ADDRESS +1~ CONTRACTOR ADDRESS well/septic <br /> VO 'cyA SSbS <br /> (City,State,Zip) (City,State,Zip) etba s <br /> M OtSCt) MI '5%—/DS <br /> PHONE PHONE ❑ Si - Plan a■- •val from <br /> (0•004• 4(95 .54 .•plica• -township. <br /> E-MAIL ADDRESS E-MAIL ADDRy S Q <br /> (ga,r1QMo (stp i• i FIAorplanstoscale <br /> ma <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Li levation of property <br /> PARENT PARCEL❑ NUMBER <br /> t?© U_B�4J ^1 �^� RRENJw�O^ING: ACREAGE:0.101 frontage drawn to scat . <br /> TOWNSHIP: SECTION: , ?J <br /> M 19150 J 3.S 1/4: N\ F I ❑ Driveway pe its <br /> 4 %° 4: (state,co ty,t <br /> ADDRESS: <br /> IAA kk.a041.0 S-r <br /> ❑ Sanita ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> '� (rub• ,private)ffiC)' 10 <br /> PROPOSED PROJECT INFORMATION, °STAF RYI" CO <br /> - <br /> PROJECT DESCRIPTION: A � ' +' : *r;- . k ._ <br /> # x <br /> . ❑This project is a new building or structure. r ,- x <br /> af This project is an addition/alteration to an existing building or structure. ,, .• Y <br /> ma . - <br /> SANITARY SERVICE: PERMIT NUMBER: � ) ° �-;��� � � t <br /> �SEWER (SEPTIC / V '� �F,^ *L a <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not incl ding basement) �� '= ., <br /> etlan• •d'� a <br /> 13 �2 , •hflre ,,, ; <br /> AREA TO NEAREST SQUARE FOOT: ; r :5 <br /> Outside dimensions including unfinished area, attached garages and above grade decks or porches) �' .- <br /> ( g ' ros i •n :rte= <br /> BASEMENT: -• 1ST FLOOR: <br /> ec) ��� 4, TOTAL SQUARE FOOTAGE 4, r o e � ® °� �,4,3i:'1 <br /> 2ND FLOOR: 3RD FLOOR: � _ -� ;_ _. <br /> .. <br /> ,,r3:i--.-„,;,1:6,1045..r.....::Itmc...t.ma,„4„, <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) �" .-1 °� �'��:1.:."=°,---?‘'�P�"- <br /> 1. The property 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 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? Eyes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? DYes 0 No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if hone) <br /> 6. Is a location survey required? (see reverse) ®Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ri]No <br /> APPLICATION MUST BE SIGNED <br /> I ` (Continue on Back) -* -* •-■ <br /> 545-112(4/08) <br />