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SUPPLEMENT to Web-App #''
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OW OR NAME
<br /> •
<br /> /h l i 1 Ai I, t Ig n Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Streeett,,City,State,,Zip) _ _
<br /> l 73 5 ttit�/� Oec11 Z 4)4,a,7 #//,'",-1, WL 5-3572 72 Deed Variance Restriction; CSM
<br /> Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> COf'-i) - fCtte.6 ha4 ,.)"ao,/`t. 4: 40a. GO n Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION = and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> n Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> applicable township.
<br /> E-MAILADDRESS E-MAILADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION" (http://accessclane.co.danemLuo/y.: _ _. - ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE:
<br /> ❑ PARCEL ,0,7_295-Y361-6 4/ 7 frontage drawn to scale.
<br /> NUMBER
<br /> TOWNSHIP: SECTION:
<br /> 5 n/h rilt.1G L y •/: 5 L J 1/1/: Ate ❑ Driveway permits
<br /> ADD Ess: (state,county,town)
<br /> 5 t-4-7 -
<br /> 4 /�ra gL 411e✓.4 "/- ,,,6 I cJT S 3 5 . — n Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> !65'77 _
<br /> PROPOSED PROJECT INFORMATION ` ' STAFFREVI 1 '"`
<br /> PROJECT DESCRIPTION:
<br /> fi P
<br /> bd r v‘ 1.2�V1— a ca l\ ® from: ® s f fit_ ,L }
<br /> . ❑This project is a new building or structure. f, "=@�z 'f
<br /> ❑This project is an addition/alteration to an existing building or structure. ri g . .4"`;.
<br /> d tr -^... RM p..
<br /> SANITARY SERVICE: PERMIT NUMBER: ,�, , ra tAth s ? ,r� 4-
<br /> nSEWER SEPTIC �[:e y!
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ' -a 3,,P.,,...,,,-,-,:-,..1.�
<br /> l °�od•
<br /> +laotean nt)
<br /> AREA TO NEAREST SQUARE FOOT: H „: -- } >a,,-'
<br /> Sgt:
<br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) - _ �'
<br /> T.!OSIOn�°p"�° °'tw„
<br /> BASEMENT: 1ST FLOOR:
<br /> /00a ,, TOTAL SQUARE FOOTAGE: j } obe :o ,21Ge` .„,,,..}a
<br /> ''r�` E Q• aCCaySS
<br /> 2ND FLOOR: 3RD FLOOR: ;
<br /> �*
<br /> logo wt,-4,,i0,-;(4j*.i,--.:*°; ; , 4
<br /> ESTIMATED CONSTRUCTION COST: - g + o ;r. F. _~e -
<br /> (Please round to nearest dollar) ♦ --11- -11. —I. —I. -10- $ 3 T „ ,
<br /> j
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [ Yes ❑No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 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 ElNo ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes El No
<br /> *I,2 APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -► =■ -4
<br /> 545-112(4/08)
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