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;;SUPPLEMENT• to Web App;#;. <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATIO N . v , , Jzu3 r ._w : - .4.-, CUSTOMER TO PROVIDE <br /> o R NAME <br /> a t li ( . 77/I/, - 0 Zoning tatus; CUP; <br /> OWNER ADDRE (Number,Street,City,State,Zip) g <br /> J1 <br /> / <( Deed Restriction; CSM <br /> 5 o(F/ P 5 e . ti _r a / ill S '3 Variance(# ) <br /> HOME PHONE ELL HONE. E MAILADEIRESS J A <br /> (6os) 2o- o,i70 (6o5) 21 oa-a-u OM. //{ `/6ou c� A of < ° <br /> ❑ Site Plan drawn to scale <br /> :AGENT?INFORMATION .; 1. a CONTRA,C,TOR INFORMATION_ and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORIIAATIONr.(httpe!/acces0Iane:co,tlane vpi.us%) , ` ::',-::"it; <br /> PARENT PARCEL NUMBER: CURRENTZON G: ACREAGE: ❑ Elevation of property <br /> El 3 NUPARCEL MBER D7I0O�IZ3 Ci� 2 frontage drawn to scale. <br /> TOWNSHIP: SECTION <br /> 1I 0OM �i 4 vo v— 5 vs: '/a'/a: ❑ Driveway permits <br /> ADDRESS: 3 (state, county, town) <br /> 5-12— PLO w v- —c <br /> CSM: LOT SUBDIVISION 'BLOCK/LOT CI Sanitary permits <br /> ( 2— C, 'Q )) A. A_,Y_ (public, private) <br /> PROPOSED PROJECT INFORMATION - S_TAP =REVIEW <br /> PROJECT DESCRIPTION: r n, K ti <br /> i ( C k n 2,6mg Dasrc r R <br /> ❑This project is a new building or structure. 0 PermlftedaUS�� <br /> This project is an addition/alteration to an existing building or structure. Key M }� �� <br /> SANITARY SERVICE: PERMIT NUMBER: 3 <br /> 07 RuTa�Address�i � l; <br /> 4Y �rr��W��S�I`�-3 <br /> EWER J)EPTIC a1 0 �l 1tg� ` <br /> HEIGHT EET: NUMBER OF STORIES: (Not including basement) 14 Y mot _ Y <br /> I/Il 44-' r QVetl 11-0/Floosi 0,-. ; <br /> os elartd` attac1.r»eflt) - <br /> AREA TO NEAREST SQUARE FOOT S+1Ja' -z -� <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) : t' tom ° p i t T <br /> Er ion -ontroi permit' <br /> BASEMENT: 1ST FLOOR: f 4 1op S a <br /> u 1 TOTAL SQUARE FOOTAGE: I f, <br /> 2ND FLOOR: 3RD FLOOR: 3 'K' <br /> I ( 0 0 - - - r.3 s <br /> ESTIMATED CONSTRUCTION COST: 3�ev avilzLocn441-Su-ey <br /> (Please round to nearest dollar) '� "� "� -ri g : _ ,; '� <br /> • <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EiNo • ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves ao ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies ao <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) [Yes �No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Bac() —► —► -+ <br /> 545-112-(4/08) . <br />