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ZONIN ww <br /> G PERMIT APPLICATION w .countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO P; 4 IDE <br /> OWNER NAME <br /> —< i I--4 " Li Zoning St- •s; CUP; <br /> OWNER ADDRESS ( ber,Street,City,State,Zip) '/ Deed - striction; CSM <br /> T� ' �-�- - Va nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ,6 • S/ , • r i i e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME /� CONTRACTOR NAME <br /> x 6))And L-• r 40-mists V o y aii L4 -S • Plan including location <br /> AGENT ADDRESS CONTRACTOP(AD ESS f well/septic <br /> (mow w . n4.*,w ate-• l 52.7z) . c..v , /447W b't-. <br /> (City,State,Zip) d,,,c.{City,State,Zip) t �_ �r Setbacks <br /> (l v d irc.,1 re's tt V JtJ z� 3 c> ft) ile,,i r`C �.l V 3 <br /> PHONE PHONE r _ m Site Plan royal from <br /> (01' • y'c( •c, ?�f 2 CLOY• T- , `lo`tj appli a towns <br /> E-MAIL,ADDRESS E d 3 Iii! LA t(` E-MAIL ADDRESS C__00.,.. 5 • 5 CI oor s to scale <br /> PRROI'ER''Y/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CUR, ENTZ ING: ACR TAG E (� p p y <br /> ❑ PARCEL O /I r .O 3 NR54 Q® -'^ -149 1 9 frontage drawn to scale. <br /> NUMBER V ` V�� Vv" <br /> TOWNSHIP: SECTI q <br /> �jyIJY�— i 5 is��i� '/4: N '/414: N ij ❑ Driveway rmits <br /> ADDRESS: _ (state ounty,town) <br /> Lo /CQ &- GtAx• 61/11/ <br /> CSM: co I 7 LOT SUBDIVISION BLOCK/LOT CI Sanitary p- its <br /> (publi •rivate) <br /> PROPOSED PROJECT INFORMATION TAFFrREV EW <br /> PROJECT DESCRIPTION: t A 4 <br /> /C) " X 27 " 1,) e _ ,- ' — • oning District 4 <br /> . ,This project is a new building or structure. '" e ` <br /> ermitted 'se <br /> ❑This project is an additio Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rura <br /> ❑SEWER EPTIC (new 7 xistin+ <br /> HEIGHT IN FEET: r ( et NUMBER OF STORIES: (Not including basement)tp I ❑ Wetland/F 0,01441V,' ,..1::,t <br /> Sho d ( tacm <br /> AREA TO NEAREST SQUARE FOOT: 'fi <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) z <br /> ❑ rvslonCont>q +er t# <br /> BASEMENT: 1ST FLOOR: / z � „s � � ",e°` <br /> �__ <br /> 3 TOTAL SQUARE FOOTAGE: open,dtstur nce i <br /> 2ND FLOOR: 3RD FLOOR: /� zi c Illing/aceeSS)t <br /> evtew Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) '♦ ♦ "'∎ '♦ ♦ "'∎ $ 1� - and available optlonS <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? R Yes ❑,No Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ;i'Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,rYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? /,gY s CI No <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) Yes ❑No Don't know <br /> 7. Is this to correct a violation? ❑Yes ,No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br /> 1 <br />