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;;SUPPLEMENT to Web App;# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION , s_ :_,, t t.s. �;'.-. C STOMER TO PROVIDE <br /> OWN R NAMME� /� �)r <br /> �e Re � 2 4e r i ('—g Qv oning Status; CUP; <br /> OWNER DDRESS Nu ber Street, t t S <br /> ( r�, city,S a e zip) / Dee Restriction; CSM <br /> /Sa7 a,/1-&/4/-/ �. 0 272)UL-74'713AS (( . 02 Varance(# ) <br /> HOME PHONE C LL PHONE E MAILA DRESS _ <br /> i <br /> . &Br% FD d 9 al C.1Plc_)Abv 1 Si Plan drawn to scale <br /> AGENT?INFO RMATIO�1 ..;.j: . r,; ; CONTRACTOR INFORMATION, , . ;- ,_ � T a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑Si Plan a oval from <br /> a plica township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION JNFORIWIATION_`=_(httpe//aecessilane co.dantz:vpi,us/), Elevation of prop <br /> e <br /> PARENT P CE N BEl LL// URR TZO G: ACREAGE: p p <br /> ❑PARCEL ��� ^ "— , �.1v 2• frontage drawn scale. <br /> NUMBER <br /> T SHIP: SEC <br /> n: <br /> N ,(� ❑ Drivew permits <br /> (�N ��4. 1 _ ��4��4. -� <br /> ADD((RESS: /, (Stat , county wn) <br /> (LS d ) �j(i l cc i A -� SMO 67// DA ❑Sanita ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (pu 'c, private) <br /> PROPOSED PROJECTr_INFORMATION; . . =q TAFPREVIEW - <br /> PROJ T DESCRIPT/IO �^ v <br /> k <br /> 0 /3 Oa 2gnIn g DIg <br /> Inct <br /> . This project is a new building or structure. <br /> `C� �ermltted ase� <br /> This project is an addition/alteration to an existing building or structure. 'sue t; .-- <br /> t Q R�ITaI :ddres <br /> SANITARY SERVICE: PERMIT NUMBER: . 'I R <br /> [EWER EPTIC `= ��{new1r lstllg) � <br /> HEIGHT IN FEET NUM R F STORIES: (N t including basement) } <br /> 7 ) Q 1EVetlar d/F •,Tarn/T <br /> S1 ioce7 d attac t) <br /> AREA TO NEAREST QUARE FOOT <br /> (Outside dimensions including unfinished area attached garages and above grade decks or <br /> porches) - aEo o��C • p BT <br /> t <br /> - <br /> BASEMENT , 1ST FLOOR: v` s1 tur o ba c <br /> `q D O 4. TOTAL SQUARE FOOTAGE j pj sa , , <br /> 2ND FLOOR: 3RD FLOOR: L/ i f � - 3"z <br /> Q :40.16 Locioue <br /> C ESTIMATED CONSTRUCTION COST: ' = rtd aaabieziptrons,♦ ♦ 3 O ©© €(Please round to nearest dollar) 1V, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 6o - ❑Don't.know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 12Fio ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes 15No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ffi o . <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) Des No ❑Don't know <br /> 7. Is this to correct a violation? DYes No <br /> — <br /> . 'sg k(f) , APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —s <br /> 545-112(4/OB) <br />