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SUPPLEMENT:Ito Web•App.#; <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION ,' CU-TOMER TO PROVIDE <br /> OWNER NAME <br /> ��Pv e �l AGO I/e- Zoning Status;CUP; <br /> OWNER ADDRESS, umber,Stre 'City,State,Zi ) � Deed Restriction; CSM <br /> if F6.5/ Age_ .Lct',i e State, la- oa-J�3- 3 Va 'ance(# ) <br /> HOME PHONE I( CELL PHONE E-MAIL ADDRESS <br /> ,01'767 57&) , 7 a2/0 a a ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) tg Setbacks <br /> PHONE PHONE n S" e Pla .•proval from <br /> p• ►.•letownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessclaine.co.dane.whusl _ _. ' levation of property <br /> ❑ PARCEL PARCEL t�UMBER: 9CP�I 7RRENTKONfG:� ACREAGE:E. 3 <br /> /J`yVC F' � / frontage drawn t cale. <br /> NUMBER <br /> TOWNSHIP k F �/ SEC I , \ ❑ Drivewa ermits <br /> !2v Ccc �-c ��' �1 ��4��4'� (state,county, t i n) <br /> ADDRESS: <br /> `/ '? 4C e L CL.-n er 4.41. S3S/s n Sanita sermits <br /> CSM: LOT 3 SUBDIVISION BLOCK/LOT <br /> 6 g (pus c,private) <br /> PROPOSED PROJECT INFORMATION rA' ` : <br /> PR ECTDESff RIPT)ON:// / ? ""` �z., <br /> �Gt-va(eN S!-°! Le t'v. .. _ • `J 13 Asnmgas nc .'' <br /> '14-:' ..-,•. IgThis project is a new buildin r structure. erml '-.• ,set; ,14---"'''':---A <br /> lyj This project is an addition Iteration to an existing building or stru ture. A` `. <br /> SANITARY SERVICE: PERMIT NUMBER ) flIRural 'r'` '* , ,, <br /> (SEWER SEPTIC F , eW extSting) �` <br /> H HT�N FEET oitt �� s g NUMBER OF?TORIES: (No including basement) ,,., r' 4 . . <br /> 11 ',VNetla •r' ..mood; a =te , <br /> l }sore s a rchment) :: <br /> I AREA TO NEAREST SQUARE FOOT: " "'- ' <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) a-<11 .. ,,.. p.. <br /> ETOS)On0on r • permit ..4 <br /> BASEMENT: 1ST O _ ..' �u 3 L-Cl"e ,,t. <br /> TOTAL SQUARE FOOTAGE: �T(s ape . l r�anCe` <br /> ,p 2C - <br /> I jU � � fillin. .ccess - <br /> 2ND FLOOR: 3RD FLOOR: (� L^ f r V` j ': S <br /> 7J t /j�X' i�4Revte .I oca orrSurveA.:' <br /> ESTIMATED CONSTRUCTION COST: )a 00 �� diva ab e , e _:. <br /> (Please round to nearest dollar) ♦ ♦ --10 --► <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [=I Yes 031No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes to ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 12nYes ❑No " <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes DR No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave bla ' one) e gut 4 Q <br /> 6. Is a location survey required? (see reverse) EYes ❑No ❑Don't know 0K, <br /> 7. Is this to correct a violation? ❑Yes g No <br /> — (0, 4 . G <br /> . , C 3 , S n APPLICATION MUST BE SIGNED <br /> -z41 ') R' Li (Continue on Back) -► -+ -► <br /> 545-112(4/09) <br />