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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 /> 0 aV I c c <br /> ae r 1r Zoning Status; CUP; <br /> OWNER ADDRESS umber,Street,City,State,Zip) Deed Restriction; <br /> � el 1� � ctlon;CSM _ �__ <br /> -3 1qa roo s i�C`\\e ) S r VV0\\C'�e ■ \\ 5355'1° Variance(# ) <br /> HOM PHONE CELL PHONE E-MAIL ADDRESS U`S� � �°�:a13-GAD6(9 c o jid e`fir o, ckcke e('e `t1et tr Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME ' I / CONTRACTOR NAME 1v <br /> AfSite N(/A Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic , 5,G' <br /> (City,State,Zip) (City,State,Zip) ASetbacks <br /> 3 7s <br /> PHONE PHONE / A E-MAIL <br /> ADDRESS E-MAIL ADDRESS 1 <br /> • <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.w Lus/) evation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: o o P P y <br /> ❑ PARCEL 09 f 13'ic g'oa A-1 a3 acres frontage drawn to scale. <br /> NUMBER ``�F <br /> TOWNSHIP: S TION: SW 4/4: 1�1 `�V ird Driveway perm' <br /> r1St4C 'r 1 1r4: HIV ' ' s - -__ •. • own) <br /> ADDRESS: 2 61 / t j a,2 \l a'1e_ RA �_ <br /> p �{ ❑ Sanitary .- ••• c.∎ <br /> CSM:t U ' LOT S - BDIVISION twA BLOCK/LOT t) A ' (publi',p ate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> W (E\\ O r I o q. rti u , r4 Zoning D strx t -� <br /> yai.This project is a new building or structure. r,® <br /> see . .\ <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> 5 <br /> /Cs -..203 . �eess <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ❑SEWER �.� EPTIC oitit-ogr‘?„..z <br /> s <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) a <br /> L"/(� A® 7- r ent) r. <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porc 0 !.,:,,..y:-.,,,L,,:! $, <br /> BASEMENT r 1ST FLOOR: , p <br /> a <br /> �!(� �I j TOTAL SQUARE FOOTAG gll A,g£ &fi ! ' sF ii a ;a - do- <br /> 2ND FLOOR: 3RD FLOOR: 1 �/,� <br /> Jigill ,— <br /> � l�ss) <br /> ' f eview-L of ,ey,, l <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ act--) ; a�[dJa1 aliabie _ <br /> (Please round to nearest dollar) $ c�C(� _I r� <br /> 4503' 41 ° <br /> 1. The property is within 300 feet of a stream or 1000 feet from a p• •• • ..-7 ... ill Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2No ❑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 X'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 - 'No ❑Don't know <br /> 7. Is this to correct a violation? Li Yes ❑No <br /> APPLICA(Continue TI on BackON MUST) BE SIGNED <br /> 545-112(4/08) <br /> —► ♦ -i <br />