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ZONING PERMIT APPLICATION www.countyofdane.com $UPPLMENT toWeb App#} <br /> PROPERTY OWNER INFORMATION ' „ _. ' t,' A„ ,. CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> I G c 4 EM tl it j <br /> kfi I 1 Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Stre t, <br /> City,State,Zip) Deed Restriction; CSM <br /> I OSS QVI►Ar. NC Variance(# ) <br /> HOME PHONE CELL PHONE E MAILADDRESS f <br /> (O —Z©6"c�j' fOZ - 11 ' • A . I I Site Plan drawn to scale <br /> "' ''' e'r' a and includes dimensions <br /> .AGENT INFORMATION �CONTItAC'FOR�1NFOi��AAT(OI���:��,,�,�;Y <br /> AGENT NAME CONTRACTOR NAME <br /> • zo Lir ki As' Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> L/ss MAT ad <br /> • (City,State,Zip) (City,State,Zip) Setbacks <br /> e luYALuS (All s39 Z5 <br /> PHONE PHONE I Site Plan approval from <br /> ‘.08—SS2 —Gg641 applicable township. <br /> E-MAILADDRESS yAIL <br /> � (ADDRESS d ` A1, com I 1 Floor plans to scale <br /> /4 r. �+ <br /> .PROPERTY/LOCATION:INFORMATION nihttpelaccessdane Co.dane wi.usliz,. ffa ;.I I Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE. <br /> nPARCEL 05'!!— D -izio-O A-I / 31� frontage drawn to scale. <br /> I NUMBER /'t C7 <br /> TOWNSHIP: SECTION: <br /> DUAL V14, 1/4: 1/41/4: Driveway permits <br /> o,� -k (state, county,town) <br /> ADDRESS: <br /> /08g G?v,' LING n Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION. STAFF REUIEVl1 <br /> PROJECT DESCRIPTION:: "- Y =• - 2 <br /> -CA/ &ered p DI -O FKIS, I �IMe. :::..:;'9.-40— mDis <br /> nc ' s . <br /> • n This project is a new building or structure. `-1� f� <br /> Permt m se_�.� �l <br /> ,This project is an addition/alteration to an existing building or structure. ' - ��,t` -. Y r <br /> SANITARY SERVICE: PERMIT NUMBER: flkR a raj�4dd es - <br /> SEWER SEPTIC new existing) > <br /> HEIGHT IIN FEET NUMBER OF STORIES: (Not including basement) 4Y: -Ai , <br /> /2 1 .PANetiand oodpiauiirA <br /> horeiand" attachment) <br /> AREA TO NEAREST SQUARE FOOT l"` ,,�" ".. x - . <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) , r„ tn, �� ' <br /> BASEMENT: 1ST FLOOR: � OSIDngOntro:`perms <br /> 96 s-p 4, TOTAL SQUARE FOOTAGE: 4, {S ieeS, anc ;*44,:* <br /> (� fitloggib cesS * �? <br /> 2ND FLOOR: 3RD FLOOR: t: a " <br /> Revtevu,'i~oca onEury <br /> ESTIMATED CONSTRUCTION COST: Q / valiab e3opfion <br /> (Please round to nearest dollar) --► --� -► ♦ ♦ --► $ /Z� 000 • . __ ._ _;;� - . .1. The property is within 300 feet of a stream or 100 feet from a pond or lake? .. DYes n No g.Don't know <br /> 2. Is there a wetland or floodplain on or near the prop rty? nYes n No Z Don't know <br /> 3. Have you talked with the township about your prof ct and are they in agreement'? E Yes n No <br /> 4. Has there been a zoning permit issued for this pro erty in the past 5 years? ['Yes E No <br /> 5. Is this project associated with a rezone/CUP/varia ce (petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) 1-7 Yes RNo n Don't know <br /> 7. Is this to correct a violation? DYes 0 No <br /> r C P 5K1 — Z D i S — OPJO 9 APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -0- —► <br /> 545-112(4108) <br />