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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME (Adieu, <br /> ,, <br /> � L�OcZ.I, Zoning Status;CUP; <br /> OW ER ADDRESS (Number,Street,City,State,zip) Deed Restriction;CSM <br /> 600;0<., I Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6112'‹ ' Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> %c7-r kte.cr �vi l rj'f,7li% ec tv57' /c r/ e1) LRSit PI including location <br /> AGENT ADDRESS / C�ONNTTRAACTTIOR/4DDRESS �,� /� , of septic <br /> 4,7G1 Pp -r t l%�' 1mac- / Y,lPf� f72 :(', /� XSetbacks <br /> city,State,Zip) (Ci ,state,Zip) <br /> - 6/7 4e C > C , / 7 5 7 <br /> PHONE PHONE Sit n approval from <br /> 'c'': 12a,46-22 (aye 3,2,s__46 ap bletownship. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wri.us/) Elevation of ro ert <br /> PARENT PARCEL NUMBER: CURRENTZONING: ACREAGE./ P P y <br /> PARCEL 3/ /&Q2: <br /> NUMBER 1 ■ Ill frontage drawn to scale. <br /> TOWNSHIP; SECTI 1 <br /> � t -- Drivew ermits <br /> 1/a: 1v }'� 1/aYa:N <br /> ADDRESS: (state, ty,town) <br /> (0>'Z/ G'ie Sanita ermits <br /> CSM: LOT S c e 10 0 .. K/LOT <br /> p-5t'v 0 (pub ate) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW` . <br /> PROJECT ESCRIPTION: ' <br /> i Of it l(a uw1 PC 1 Zoning District <br /> ❑This project is a new building or structure. Permitted Use? <br /> A-This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Runs '1W i. ` <br /> SEWER 0 SEPTIC N (ne �iriopt *V, .;';01, <br /> HEIGHT IN FEET I f NUMBER OF STORIES: (Not including basement) ,s o <br /> AREA TO NEAREST SQUARE/FOOT: <br /> (Outside dimensions including unfinished area, attached garages •and above grade decks or porches) • : ' .. <br /> BASEMENT 1ST FLOOR: -. ; ,,.- <br /> �� 2 0 4, TOTAL SQUARE FOOTAGE: 4, ,d , <br /> G w� <br /> 2ND FLO R: 3RD FLOOR:, . <br /> �- lU <br /> �� t� � --- � ,,,Review i `4i <br /> ESTIMATED CONSTRUCTION COST: '' <br /> (Please round to nearest dollar) "� "� �' "� ($ � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes arNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑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? ❑Yes liallo <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 j4No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -+ ■ -0 <br />