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;$uPPLEMENT tolot App#.`.
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY OWNER INFORMATION ,- s . _ f, _ r. , ..w.. `z ,,.; CUSTOMER TO PROVIDE
<br /> OWNER NAME A---- rf
<br /> Ol4 it /) it//r I' ► Zoning Status; CUP; (�--
<br /> OWNERADDRESS (Number,Street,City,State,Zip) 1` „„---
<br /> s
<br /> � � -, � i eed Restriction; CSM
<br /> 62 S& C t 3 /`/c✓;/ /4 b-4 •� ; ta/i. . - Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS -
<br /> ZCe - %e-;1 a (tls A:7/-4') 1. 1 Jo k, nv,. //,'. Ci.0 ,m<< ; c'v-- Site Plan drawn toscale•
<br /> AGENT INFORMATIOj 3 ;CONTRACTOR-INFOROTlON_, ,, ° and includes dimensions 6Sik
<br /> AGENT NAME CONTRACTOR NAME
<br /> a Site Plan including location 36.0
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,State,Zip) ►� Setbacks `©6/5/04
<br /> PHONE PHONE ICI Site Plan approval from
<br /> applicable township. n fti
<br /> E-MAILADDRESS E-MAILADDRESS ,"
<br /> Floor plans to scale
<br /> `PROPERTY/LOCATION`INFORMATION> :(httpel/accessdane.co,dane vpi.us!) i =; ,I
<br /> PARENT /' E UM RRE TZONING: ACREGE: �L1 Elevation of property
<br /> ' NUMBER igs,_pS-3 `��1Yf. 1-- ,25, frontage drawn to scale.
<br /> TOWNSHIP: f . SECcTIION: �-` /// 1�y°.•._ _y permits
<br /> " " '"%' '�' ✓ ��' (state :aunty, town)
<br /> ADDRESS:
<br /> 64.34 l, S ,t-/i,/,./ /� �v..;•- , w J:?� (j unitary .- slits
<br /> CSM: LOT SUBDIVISION 'BLOCK/LOT (publi- •
<br /> PROPOSED PROJECT INFORMATION.
<br /> PROJECT DESCRIPTION: I s STAFF REr71EIlV
<br /> J �[ L
<br /> r / ' S l 7 f2Z� ZflnmgDl$tkrs
<br /> 21This project is a new building or structure.
<br /> '� Permlft�d 1Jse'� ��j =Q±
<br /> This project is an addition/alteration to an existing building or structure. t. W ="
<br /> it;Z 1
<br /> SANITARY SERVICE: PERMIT NUMBER: �,R�T-atA °� A'
<br /> rM s � 3
<br /> EWER EPTIC w' �, T10,W ^�-•S a-
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) { '- /�
<br /> / IEtlailC�/F�O06,-ltl/= 1
<br /> �( �'� ./ Z .� ..Or �— / _ $,S#oge1aMcfa#acreftt):
<br /> AREA(10 NEAREST SQUARE FOOT _ -4
<br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) -E -�. - 9�o
<br /> BASEMENT: 1ST FLOOR: E[D_]-. C'. C� p_er[T�It'
<br /> ' �� `� '1' T°TAL SQUARE FOOTAGE ` S)O)3 S �t,StUTb1Ce /
<br /> 2ND FLOOR: 3RD FLOOR: '. 0 N 0 OCeS i- `; a , i �r
<br /> G, 6 e l� � t evlevt� ooatloF S;1:Jrey !)..f:ti.
<br /> ESTIMATED CONSTRUCTION COST: _ d r_,. ys � `
<br /> —► =► —► ♦ —► —r / v =3t` a� abrez3,ptto�sy 4,...._
<br /> (Please round to nearest dollar) �C� �- fJ _ a�
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYes [, ]1lo ODon't know
<br /> 2. Is there a wetland or floodplain on or near the property? [fres ENo QDon't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? ®,t'es ONo
<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) .... [7]Yes ENo • ❑Don't know
<br /> 7. Is this to correct a violation? \ es ['No
<br /> . S 2 3—/- AP•LIGATION MUST BE SIGNED
<br /> ontinue on Back) —► —, —►
<br /> 545-112{4108) .
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