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• ' ti-f-c-e <br /> • vl � <br /> • <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> OWNER NAME n CUSTOMER TO PROVIDE <br /> Gcegocy a✓`� M cif I'�ees ❑ Zoning Status;CUP; <br /> OWNER ADDRESS umber Street,City,State,Zip)( <br /> LH O( Fo, c'e Trct:l 1'l 1 s?Vo/� Li S3S62Z Deed Variance Restriction; CSM <br /> / � Variance(# ) <br /> HOME PHONE CELL PHONE / E-MAIL ADDRESS <br /> 836-3��� i-ee-5 ae`-€'1`7.e"'4^ f9 s e Plan dr wn to scale <br /> • d s <br /> AGENT NAME CONTRACTOR NAME <br /> l0,8tfe Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS offw�well/septic <br /> Ly <br /> (City,State,Zip) (City,State,Zip) 'Setbacks <br /> PHONE PHONE V Jlie Plan approval from <br /> applicable township. _ <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Di Floor,pl s scale <br /> W <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ion of property <br /> Li NUMBER ,PARCEL 0706263--5070-0 R H `3 //, g4/ ✓frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> Vec IAA 0" c 26 ,�4: NE 1/4%4: SW lij,Driveway permits <br /> ADDRESS: 55x 14 J (state,county,town) <br /> CSM: L DIVISIONS' BLOCK/LOT Sanitary permits <br /> -Z44'g z (public,private) <br /> PROJECT DESCRIPTION: C� aF REVIEW <br /> New House_ Zoning District <br /> . $, This project is a new building or structure. V.Krmitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Li Rural Address <br /> ❑SEWER XSEPTIC S 2o37 Li- xisting) <br /> HEIGHT IN FEET: NUMBER O TORIES: (Not including basement) <br /> 2Y- ' RE .. etland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: 'hOreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) 1V+' <br /> �s stun ontroi ?Prrnit <br /> BASEMENT:NT:q 2 1ST FLOOR:Lte 1 TOTAL SQUARE FOOTAGE: slopes,disturbance, � <br /> CC{{!L. 22 'I +r.«.��.. <br /> 2ND FLOOR: 3RD FLOOR: � j-�� / <br /> c C3 DO 0 tr`"" 6 2-64 Ii Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: yfso and available Optiarts. <br /> (Please round to nearest dollar) ♦ ..+ ♦ 1 DO 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IN No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes N-No ❑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 , 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 to ❑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 />