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,;:SUPPLEMENT to:,W, ...4k. . <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWN ER INFORMATION e: CUSTOM TO PROVIDE <br /> OWNER UsAME <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> oning Status; CUP; <br /> .7g i v 6 C; -wL- a��I_ Deed Restriction; CSM <br /> Varia e(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 98/(o•3G ----- S. Plan drawn to scale <br /> =AGENT INFORMATION,- • , CONTRACTORJNFORMATION- °g and i cludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> itzw ,•� 4'"� tcov"f/- ite Plan .ncluding location <br /> AGENT ADDRESS� CONTRACTOR ADDRESS • of Wel eptic <br /> £' <br /> 141/ c "kw/ <br /> (City,State,Zip) (City,State,Zip) <br /> c_r tbacks <br /> /14 ".dJe_e41 W/ s7rlo <br /> PHONE PHONE ❑ Site Pla, approval from <br /> CODS' k3(o /hors appli;,1 k , nship. <br /> E-MAILADDRES A /� E-MAIL ADDRESS <br /> "oiW 4weekf' ev�y✓�CA..v,Si rt,K.-..,• a N. co,M F •Or S to scale <br /> PROPERTY/LOCATION INFORMATION (httpel/accessdane:co,dane:wiusi) '::..';.:2`,;, E vation of property <br /> PARENT PARCEL NUMBER: CURRE TZDNING ACREA <br /> ❑ <br /> PARCEL \ J rontage e drawn to scale. <br /> NUMBER n�U 3nS dC)G.�l / g <br /> TOWNSHIP: [ a S TION: <br /> 1 1 �L1 n 1/: J UV 1/o : ❑ Drive ermits <br /> ADDRESS: Cr)(� (5 C Unty, town) <br /> --) 5.. (—) Se/E'11- e4-C$M: LOT SUBDIVISION BLOCK/LOT ❑Sanl - pe -its <br /> I 09 <br /> I (publi ,•ovate) <br /> PROPOSED PROJECT INFORMATION , z, S: AFI=REVIEW <br /> PROJECT DES�R IPTION: °° <br /> 0- e 41,Gr4�.- 4,--, J /"/� il- nmg S,IfibtitAWiLV <br /> t <br /> . QThis project is a new building or structure. ?IR Pe Itted Uses t <br /> This project is an addition/alteration to an existing building or structure. ' � 3Tt� <br /> SANITARY SERVICE: PERMIT NUMBER: 41 �,R r I A•• i . <br /> EWER EPTIC k lginew !S1 �.. <br /> -sue"� = <br /> HEIGHT I ET NUMBER OF STORI : (Not including basement) 3�4 - , ' `' <br /> r i Q�111/e(lar� / •lalnf F`B <br /> 3 s - B1$L ,e Iattac meet) <br /> AREA TO NEAREST SQUARE FOOT: 5- <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) _. i i <br /> ❑�1=�oto a ntr�fipe:rtralt _. <br /> BASEMENT 1ST FLOOR: N •- a �- �, _ <br /> Q — .ii- ( j TOTAL SQUARE FOOTAGE ,, s % , uT-baf ce, , <br /> 2ND FLOOR: 3RD FLOOR: N , ; 2 3 ',-�' <br /> . /( <br /> ' I evie 1 ` ey 'd ) �� fls ESTIMATED CONSTRUCTION COST <br /> "� � � -rJ C(Please round to nearest dollar) t : ,-: t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ® [-Pon Don kn�. <br /> Lives <br /> 2. Is there a wetland or floodplain on or near the property? Elves o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? kl es [LiNNo ��y <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? II es ❑NO � ? <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) P. 1 es No ['Don't know <br /> 7. Is this to correct a violation? ; Elves 'JNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —o. —► —► <br /> 545-112 j4/os) <br />