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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENTto Web-App# <br /> PROPERTY OWNER:INFORMATION _ '�1U{ ;,. . ., ;.:.-_•:.-.:=',.....,:,51',=;:-_111. <br /> �' 0 NERNAME "r CUSTOMER TO PR VIDE <br /> 11..{{ Q n 1 �" r i1 f ❑ Zoning Stat ,CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed R riction CSM <br /> a -nQ C'_JeorUIC' o i c2 CCtm41C Luz_ S3 3 Val' ce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> — <br /> q61-.0 • 0 • ' gli Ite Plan drawn to scale <br /> AGENT INFORMATION .: ; ; CONTRACTOR INFORMATION ; ' ;: ,; and includes dimensions <br /> AG NT NAME CONTRACTOR NAME <br /> SSG/Yl(a P t W 3tO O r th Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> LL -789i She Yt Rd a <br /> (City,State,Zip) (City,State,Zip) 1l1 Setbacks <br /> EU,{4 l(- or) /0 SS <br /> PHONE PHONE • ❑ ite Plan royal from <br /> 9,x() - 3q 7. 010,S- applic e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> lour plans to scale <br /> PROPERTY/LOCATION:INFORMATION.(http://accessdane.co dane.wi.us) ;; <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: A Elevation of property <br /> W NUMBER 0241107/2-333 s'i -a CA" 2(z) 02 .3 4 J b frontage drawn to scale. <br /> , TOWNSHIP: SE.7 • � 1 �- <br /> 2P� �e I d l/: S.k) wk. lv I_ a Driveway permits <br /> ADDRESS: n ` I k0 (state,county,town) <br /> CSM: LOT V SUBDIVISION BLOCK/LOT Sanitary permits <br /> IC? / I tUi- (public,private) <br /> PROPOSED PROJECT INFORMATION. 3 <br /> PROJECT DESCRIPTION: ^J\ l 0 A x� x F t1 <br /> ®This project is a new building or structure. �= <br /> ❑This project is an addition/alteration to an existing building or structure. r" <br /> SANITARY SERVICE: <br /> PERMIT NUMBER:��� .a a�� * i g'' " <br /> a � -•❑SEWER ASEPTIC <br /> HEIGHT IN FEET n NUMBER OF STORIES: (Not including basement) ` R <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) a` � i ' <br /> BASEMENT 1ST FLOOR: ,;_�"�,I Ir��r �, <br /> 4, TOTAL SQUARE FOOTAGE: 4, e -- ` 1 . ;y I I <br /> 2ND FLOOR: a ) ° � A t� <br /> 3RD FLOOR: <br /> r > ' <br /> y ESTIMATED CONSTRUCTION COST: ii .. t g V��• e—• " —• " $(Please round to nearest dollar) V 0, tj t = :7,1 ?__g"1 <br /> -.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Tes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑ es No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (I ave blank if one) <br /> 6. Is a location survey required? (see reverse) Yes ❑ o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► —► <br />