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ZONING PERMIT APPLICATION www.countyofdane.com ;`SUPPLEMENT to;lAleb App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> jl le -') <br /> 1N FOR ng Status; CUP;O ERADESS <br /> ( t��,Street,City, ate,Zip) �� Deed Restriction;CSM <br /> —;n ) n <br /> 'l /` e''''^ 5I - Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> `5 / <br /> .� � Ite Plan drawn to scale <br /> AGENT;INFORMATION ".?.. ,,,,; ,CONTRACTOR_INFORMATTION,' ;„ and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> . ite Plan including location <br /> AGENT ADDRESS CONTR CT ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) aCks <br /> PHONE PHONE ©Site approval from <br /> a licab township. <br /> E-MAILADDRESS E-MAILADDRESS - . <br /> oor plans to scale <br /> PROPERTY/LOCATION`INFORMATIONp I(httpel/accessdane co,dane vi.us/) - _- evation of ro e <br /> PARENT PARCEL NUMBER: URRENTZONING: ACREAGE: <br /> El p p rtY <br /> NUMBER Ptb9$ ac 4 $-mss 0 K---34 -7 a.xi / S frontage drawn to scale. <br /> TOWNSHIP: - TI <br /> yi: ��f IA.1/4: D ••- - •-rmits <br /> ADDRE7 Li 9 Q Stat- •,nty, town) <br /> l<`)1,°"_ ' `s 7 Sani':•. .ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> PROPOSED PROJECT INFORMATION;' S STAFF WAN <br /> PROJECT DESCRIPTION: a � a <br /> 12-eS gtor�,e nmg Dls r�ct E N <br /> •['This project is a new building or-structure. P Ifted User Z <br /> ❑This project is an addition/alteration to an existing building or structure. z'Segf_taltitilIMAN <br /> kv. s SANITA <br /> RY SERVICE: PERMIT NUMBER FIEWER 17.9EPTIC Ir �. 5 -Riew e c'4 ' <br /> HEIGHT IN FEET NUMBER OF S ORIES: (Not including basement) k a <k "_ .y.4�, <br /> = YS • a d' "attac1me-) - <br /> AREA TO NEAREST SQUARE FOOT �0 L <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches)•BASEMENT 1ST F OOR: - s)oiaC-ontroTperrnjt-� ' <br /> • -, Y .' <br /> 1 TOTAL SQUARE FOOTAGE: 1 i ItliMtsturballce,_'may_: <br /> ccess <br /> 2ND FLOOR: 3RD FLO R: .tom ti, e x . ,., <br /> evievt�locatbn S(J >ry <br /> ESTIMATED CONSTRUCTION COST: {1d- aa(3{eit X71 <br /> (Please round to nearest dollar) 1,- lO 4 P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYeso.•• DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes o DDon'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? Lives 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) Rr'es ENo DDon't know <br /> 7. Is this to correct.a violation? Dyes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ♦ -Jr- <br /> 548-112(4/08) - <br /> • <br />