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ZONING PERMIT APPLICATION www.countyofdane.com E=23===! <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME k 4 A, i C? t, 2 ❑ Zoning Stat UP; <br /> OWN ER ADDRESS (Number, t)et,City,State,Zip) Deed Re Iction; CSM <br /> 1 <br /> _ .: ari e(# ) <br /> HOME PHONE 'CE PHO E E-MAIL ADDRESS <br /> G -3 '-WS' -I cc? - a i . . - - Q r/-/ . f-- s S' e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Oa 1 Q 0 t eesSe w 5 Si Plan including location <br /> AGENT ADDRES C� � 1' CONTRACTOR ADDRESS well/septic <br /> '�'� 9z 0 /I'?441,... <br /> (City,State,Zip) (City,State,Zip) ' Setbacks <br /> d e,..1- L1:_ 53'67 <br /> PHONE PHONE ❑ Site Plan proval from <br /> ..'6,) 7Yy-ZG9`t 776'2OY( plic a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ad re.e S s 6.4 OA 4k t , e}- oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJlaccessdane.co.dane.wLust) Elevation of property <br /> PARENT PARCEL NUMBER: CUR ENTZONI G: \ ACREAGE: p y <br /> PARCEL uu i\ ' (,RJ 9, 32 /3 fr ntage drawn tgscale. <br /> NUMBER ! 0tOt7(cr.'7Z'L"( S�O'C7 <br /> TOWNSHIP: SE 'A � <br /> „ f Y4: 111 '/1/4: V� ri way permits <br /> B/ <br /> +tee m-ow (s te,county,town) <br /> ADDRESS: <br /> 7 yo i Nzw L., E M c;"4 #0,e6 53572, <br /> cSM: I I OT SUBDIVISION BLOCK/LOT anitary permits <br /> 1/ y L I (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: r fir, s^ I ' <br /> ---- ,cam I Wing District <br /> . &this project is a new building or structure. QdR <br /> 8_A,_nS ermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE. ,,��'' PERMIT NUMBER: a •ddress <br /> if� <br /> SEWER SEPTIC a 5/e Z. Y7 (r ew/:xisting) <br /> HEIGHT IN FEET: e NUMBER OF ST RIES: (Not including basement) <br /> VAIL - /© _ I - W and/Floodplain/ <br /> / AREA TO NEAREST SQUARE FOOT: oreland (attachment) <br /> (Outside dimensions including unfinished area, attached garb,-s an. • e grade decks or porches) <br /> BASEMENT 1ST FLOOR: ErosionControl permit <br /> 'Y TO'•L SQUARE FOOTAGE: + (slopes,disturbance, <br /> Ar•air =1V;411111111 'W- '.. filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> _ ~'7 ' ❑ Review L• -tion Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q and a : able options. <br /> (Please round to nearest dollar) •V 600 000 . --' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ElYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI-Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? aYeS ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan I none) <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 /> (Continue on Back) ♦ ■ —► <br /> 545-112(4ro8) <br /> -14G z---(f, <br />