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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME <br /> CUSTOMER TO PROVIDE <br /> Mod ' ' L0AP Z i c ❑ Zoning Stat UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 2141 6 Sp p i ry Roc e Rd V w„N cur- Deed riction;CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS s 39J tie(# <br /> ) <br /> a'it e r~' /�A',G�aA�/G''''' e'er�" Site Ian drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION an includes dimensions <br /> AGEkg NAME CONTRACTOR NAME <br /> /► I c �/i At' 51-- ,SA.K e /fs <br /> AGENTADDR S / ` ��Od✓7 it Ian including location <br /> I CONTRACTOR ADDRESS of ell/septic <br /> Z `l/6; Sr/ 'it-7 Post ( d) <br /> (City,State,Zip) (City,State,Zip) <br /> V C r o r\-,c-,_ (n)l 5 )s--5 Setbacks <br /> PHONE PHONE <br /> f- Z 2 C 3 ❑ Site Ala proval from <br /> 6 O r ey <br /> ap le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> NI 6or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL <br /> NUMBER ()6°k-191-f5745--0 L •/ S-. Z frontage drawn to scale. <br /> TOWNSHIP: SECTI N: <br /> Vreem- _ y6 y4y• ❑ Drivewa ermits <br /> ADDRESS: (sta ,county,town) <br /> Sp tVJF�M� GO' <br /> ❑ Sanitary <br /> CSM: Y/ w J^t��' LOT S! SUBDIVISION BLOCK/LOT rmits <br /> I�( O� ( (pub' ,private) <br /> PROPOSED PROJECT INFORMATION y. <br /> PROJECT DESCRIPTION: <br /> • ,r ttts project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. € -s �& <br /> SANITARY SERVICE: <br /> PERMIT NUMBER: .4 1,::; til„*-41,,,,,. tyz,,,,,,,,,,,4,„,4 <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: �� NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: _ '� � t <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) t=` ? 0 � <br /> BASEMENT: 1ST FLOOR: W " • <br /> 4, TOTAL SQUARE FOOTAGE , -: t m, :i s Bn a , r <br /> 2ND FLOOR: 3RD FLOOR: � , ,r <br /> 25'410 <br /> ESTIMATED CONSTRUCTION COST: 4 ` <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ "► $. 410 00, ' a',S' 'pi O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes J No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes J No LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? -❑Yes I No <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 'No <br /> j q i‘) APPLICATION MUST BE SIGNED <br /> 545-112(4/08) �! (Continue on Back) —0. —► —► <br /> II 6 C <br />