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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 /> l&v y (+4 I ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Nurriber,Street,City,9pate,Zip) Deed Restriction; CSM <br /> VQ-15 if i 1.! kd, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> i 615---217- 657( ev Pre_IAJ Jt� , (0 4 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT, ME CONTRACTOR NAME <br /> :..-)oh. rt--- /1/9 j. JQ 4., ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS Alt- of well/septic <br /> ti e. Oe4a \ A-"?-- pit t. Pao, . <br /> (City,State,Zip) (City.State,Zip) LI Setbacks <br /> Ma/ „ i.ed 1 :,T?lx 11A4.t ch., wt- 577/4 <br /> PHONE PHONE ❑ Site Plan approval from <br /> C Or- Zo - /J '` 6o - 2 f- 1 I f applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> JO A- yt :X../a314" 4.1...v, wA" joA,4.4akt to ay e G.;di+v. Utz^. ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usr7 ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p <br /> ❑ PARCEL 0/8 /b�l$ �� - C1L �/ frontage drawn to scale. <br /> NUMBER / / '� l c }e+,f <br /> TOWNSHIP: SECTION: <br /> l dv& of �i tire Crov(� ,/4_ ,/4/: C3 Driveway permits <br /> ADDRESS: (state,county,town) <br /> L1o75 v1145 <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVSION BLOCK/LOT <br /> 3511/- (public, private) <br /> PROPOSED PROJECT INFORMATION : <br /> PROJECT DESCRIPTION: e 5a 8 #a <br /> ��M411 tti, '. d .v..- <br /> . CJ this project is a new building or structure. � ,$ q <br /> ErThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: _ '‘:1,,4',.`t-',-,-,.',,,,,_ <br /> r $`, € u❑SEWER ‘TIC / nz9. 1Z > � <br /> HEIGHT IN FEET: i t NUMBER OF STORIES: (Not including basement) - <br /> , - <br /> AREA TO NEAREST SQUARE FOOT: <br /> r ' V a gas' <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) _ t p? <br /> BASEMENT. 1ST FLOOR: --, �. <br /> cZ-Zr 4, TOTAL SQUARE FOOTAGE: 4 z, 1' <br /> 2ND FLOOR: 3RD FLOOR: 2"� �; e, <br /> ESTIMATED CONSTRUCTION COST: ,�y�(� '` I _ : <br /> (Please round to nearest dollar) -► � -t — —0 -+ $ ���-3600 - ;_, �' �- <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No iJDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑`,Yes ❑No D15On't know <br /> 3. Have you talked with the township about your project and are they in agreement? I:Yes Li Np <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes QPNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank pone) <br /> 6. Is a location survey required? (see reverse) ❑Yes Ily ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes L o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 --. <br /> 545-112(4108) <br />