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ZONING PERMIT APPLICATION ww.countyofdane.co111 SUPPLEMENT to:Web•App# <br /> w <br /> PROPERTY OWNER INFORMATION . CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> j r// S/. / //Z ,6X4/v '— 5/i //9Z / 7-2ni <br /> Zong Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> c2 0 67 yrn /J/4 004, Variance(# ) <br /> HOME PHONE CELL PHONE E-m AIL//AppDRESS ,44r.r. <br /> W. 5'7'••/ ©Y �4f'-3.j? -`./3?3 tie ft /SG 411iTz ® $5CJ46/ 4 Site Plan drawn to scale <br /> AGENT INFORMATION _ CONTRACTOR-INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT ADDRESS f CONTRACTOR ADDRESS of well/septic <br /> (City,sate,Zip) / (City,State,Zip) tbacks <br /> PHONE / , PHONE Si Plan approval from <br /> plic le township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION:'INFORMATIONc.(http://accessdane.co.dane.wi.us/) : Elevaf operty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI <br /> ❑PARCEL fron awn to scale. <br /> NUMBER o6Il -fall-n6oi -7 R a 1 ��� , S <br /> TOWNSHIP: SECTION: <br /> n 1/4: 1 F W/4: riveway permits <br /> 0" (state county,town) <br /> ADD ESS: <br /> 9 O \/ l <br /> 7` a'"�'�� anitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT • ate)El'10 <br /> PROPOSED PROJECT INFORMATION ! STAFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> by.e-Ck /f; ./67 // coning District = {•❑This project is a new building or structure. ermltted x <br /> Use? <br /> oThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ral Address <br /> J \� T <br /> EWEREPTIC j J� neW <br /> HEIGHT IN FEET NUMBER OF STORIES. Not including basement) etl,„. z. OQdpl,,-- <br /> chmntj <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) OflCO , il permit <br /> BASEMENT: , 1ST FLOOR: <br /> G. - j TOTAL SQUARE FOOTAGE: 1 slop ,sturbahce, � <br /> 2ND FLOOR: 3RD FLOOR: s r�•/ Review Lo• tlon Stuvey <br /> ESTIMATED CONSTRUCTION COST: $ ) Sn0 and avrailabl options <br /> (Please round to nearest dollar) - ♦ ♦ '♦ ♦ $ J .\/11.0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Wes ONo • ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? a es ONo ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? L. -s ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? a es No . <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) Dyes No ODon't know <br /> 7. Is this to correct a violation? DYes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —I► —► -♦ <br /> 545-112(4/08) <br />