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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> r, , ,_ <br /> SC 1/4r"f oning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) �^ - / Deed Restriction; CSM <br /> ad 75 TWe, ;3," C-fdt `� lu-Pr 1�& ai.2- 535-38, Variance(# ) <br /> H ME PHONE CELL PHONE E-MAIL ADDRESS ``�� <br /> Gog c YT- %G S" `( e� SG .T�F /"ter 11' 5!:'`M ®-Sife Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> L ' 'Y or D'5 (17"le 9 /!e [Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip)--GG ``�- e tbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> ('(opb') d .- p--- 37/ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 15 &11 Li /.r 41,,,,.PS. c or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> -ARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ►� PARCEL ob 10- . -BSoo_ frontage drawn to scale. <br /> UMBER D(a/O-3al �1SG'-S 1� �^ $ 1/ �S <br /> TOWNSHIP: SECTION: /�� <br /> - 1/4: 4 ' 1/4'/4: N4 S D . -wad?...-rmits <br /> ADDRESS: -tate efalfirito <br /> CSM: LOT SUBDIVISION BLOCK/LOT anitary !.�-=• s <br /> (publi private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: � � <br /> � e`v 7r/P a ,' 1y o�.e Ln� : z <br /> S H <br /> . -This project is a new building or structure. to°U ? <br /> � ii�Uae. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: , Ie1C f <br /> 3--�-O! ©o 88 . <br /> SEWER �EPTIC / �- � � " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3s�' G�- J a We llrloodplainf <br /> AREA TO NEAREST SQUARE FOOT: t , <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: / CI 8141,,' <br /> 3 e a 37 a y + TOTAL SQUARE FOOTAGE: 4, sloe wan€e, <br /> 2ND FLOOR: 3RD FLOOR: �, � <br /> /(gy 783 ,/,, <br /> Re , £ocation Sury it <br /> ESTIMATED CONSTRUCTION COST: / O <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ /O 0620. O 5 �5 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 01Qo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes g.Wo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Qs ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Et‘ <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) Eyes r91 Imo Don't know <br /> 7. Is this to correct a violation? ❑Yes 13 o <br /> � � APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -* <br /> 545112(4ros> <br />