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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME c1&4_ r I eV\ Elo.ning Status; CUP; <br /> ER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restricts Fn; CSM <br /> 213 S tIckc y5c e U rt S'�o \k4-Un WI �� Variance(#OZc31 } <br /> HOME PHONES CELL PHONE E-MAIL ADDR SS <br /> 1 715-5761-267 le„. t# e, ' t‘ ` Cow ,,,-- <br /> i. ste Plan drawn toscale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CO TRACTOR NAME <br /> IKNNICI✓L-SOrekt In eI'WI Et to Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3537 F-ein,-f-e 0 0. <br /> (City,State,Zip) (Cty,State,Zip) Setbacks <br /> Mac son t' 33718 <br /> PHONE PHONE -Site Plan approval from <br /> GO/— Li-3 ._31 1 I applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Y` co/3 Wal1teiry a 1 ( e CDpvl EKloo lans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) levation of property <br /> ❑ <br /> PARENT PARCEL NUM ER: CURRENT ZONING ACREAGE: <br /> PARCEL OS// /$- cI//) 9 l C( frontage drawn to scale. <br /> NUMBER f q 4� + ' ' <br /> TOWNSHIP: r-\ SECTION: <br /> ...AA nki r k— PLC) 1/4:N E '/4'/4: Driveway permits <br /> ADDRESS: <br /> (state, county,town) <br /> between rte, 7� Ct� i a h p,1,---c P NIA] w-t-0 f S-e c 2 <br /> .... <br /> OZnitary permits <br /> CSM. SUBDIVISION BLOCK/LOT <br /> pct . 26 0 312- 7 Li s"I vd p c� 2_616--2.6-17 (public, private) <br /> :PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> • <br /> 2OJE CRJ <br /> l,o DES n S t PTION ru� elk) 1,..,P5 laic t 4l,a \(1 d its IaJ''Loning District <br /> . is project is a new building or structure: ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: urai Address <br /> FIEWER IX6EPTIC j 2.01G— 000-3G ° �c xisting) <br /> �'l <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> �3 �' OH e A -tland/Floodplain/ <br /> attachment) <br /> REATO NEAREST SQUARE FOOT: <br /> ° �16- <br /> (Outside dimensi including i ifinished area, attached garages and above grade decks or porches) FOSIoncontroI permit 7` <br /> BASEMENT: 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> >�one_ —.510119 i 5 2- filling/access) <br /> zNy07 e 12_1-- c 6 �1 ct ru3 e- 516 pok -D 2-,5 (Z <br /> eview Location Survey <br /> ESTIMATED CONSTRUCTION COST: `, and available options. <br /> (Please round to nearest dollar) ♦ -"• --∎ ♦ -► -* $ 1 bQj 000 <br /> Y-i,lQr <br /> 1. The property is within 300 feet of a str9Par 1000 feet from a pond or lake? 1'es ❑No Don't know <br /> 2. Is there a wetjjand or flocuiprain on or near the property?...W.e.C.fi°.c.v'f. L4es ❑No EDon't know <br /> 3. Have you talked with the township about your project and are they in agreerrlent? Ek -s ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 1111 es ❑No, 01 4— K-Kov✓ <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> Is a location survey required? (see reverse) ❑Yes Fig♦o ['Don't know <br /> Is this to correct a violation? ❑Yes im o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ■ -i <br /> 545-112(4/081 <br />