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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CU OMER TO PROVIDE <br /> OWNER E _I.. <br /> t 1� 1 �Zon�g Status;CUP; <br /> OWNER AD 'ESS (Number,Str�City,State.Z ) <br /> v0g S ri VA T (1 heed 20 D9ed Restriction; CSM ) <br /> V (. Vanance(# <br /> HOME PHO E ELL PHONE E-MAIL AO RESS <br /> St F52L) £3trt ff k-ie_20140 #'t` kil i'Gom d Ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION fnd �icludes dimensions <br /> AGENT NAME CONTRACTOR NAME J <br /> ., - t „oPirff'"— Rkri )Tc,1/'Y ' Mre—c '®Site Plan including location- <br /> AGENT ADDRESS CONTRACTOR DR of well/septic <br /> �- 1 f r YY Pfd `'�.F t(1, ! 1/orttry\ Setbacks <br /> (City,State,Zip) State,Z'p) j( - -� <br /> I:2/11C ra \Nit F-3. (-1 Nk e. curt s U 1 ❑S e Plan proval from <br /> PHONE(0b?) 43-1 c (Q(Th �� 1 fPP) e townshiP. <br /> E-MAILADDRESS E-MAIL SS , <br /> '„t kcJ-1 I de ,� )j;alr v-YtS1-1 de ni.corn F or plans to scale <br /> PROPERTY/LOCATION INFORMATION {It tp:llaccnssdane.co.dane.wi.ust} <br /> a <br /> PARENT PARCEL NUMBER: CURRENT ZONIN G: ACR GE: y EI vton of property <br /> y <br /> Q PARCDL R _ J"90 U_3 'A-'1'Z 14, ( o y firiontage drawn to scale. <br /> le. <br /> TOWNSHIP C TI N: <br /> r r __ I . 'h: . V\1 '/,1/.: Driveway permits <br /> ADDRESS: ate,county,town) <br /> ' C6 tom-" Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (p blic, private) <br /> PROPOSED PROJECT INFORMATION 'S AFF REVIEW <br /> PROJECT DESCRIPTION: �-., ( i / <br /> ' f . ,' y rot -' l / . ' Z.• ing District <br /> . This project is a new building or s�cture. t,Ur'\. IN •ermined Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ®/ ' 1, : Address <br /> FIE R--�. " EPTIC 43—'2OI(0 (y)c. 5r. ew/-xisting) <br /> HEIGHT IN FEET: 11---- NUMBER OF STORIES: (Not including basement) r'etland/Ft plain/ <br /> hovel (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions me u ing unfinished area,attach gars and above grade decks or porches) .... . nfrO 1 permit <br /> BASEME1014— (.`� (I 1ST�LOO. � '? <br /> ` 4, TOTAL SQUARE FOOTAGE: 4, (slopes, sturbanCe, <br /> 2ND f OOR: (wage.) Grl <br /> ling/ @SS) <br /> vin tt ? <br /> ( Review Location Survey ,'e....c <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ -► ♦ �/� and available options. <br /> (Please round to nearest dollar) - `� / aDo <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies Oslo UDon't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes gi! o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ■ 0 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) es 'f,;, o ❑Don't know <br /> 7. Is this to correct a violation? EYes ! 0 <br /> APPLICATION MUST BE SIGNED <br /> sae-ttz(aiae) .A. III r <br /> 5 I ._..� (Continue on Back) <br />