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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION
<br /> OWNER NAME CUSTOMER MER TO PROVIDE
<br /> (.G LS crit aot,L,
<br /> ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) -
<br /> g�ctU Q'u1'� , .� c der' -zL- (roc(3 Deed Restriction; CSM
<br /> HOME PHONE CELL PHONE E-MAIL AD ID RESS Variance(# )
<br /> 0q 7 3 `tct`1 C'/ --7733ct9`/-1- ccro -op/dot a usc'ed (iv cc,,,,J
<br /> ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRAi TOR NAME
<br /> /—f c( AlrYi 3U'0C elo 7--MC .ti? C 'Ccr)rcf wicaes j ❑ Site Plan including location
<br /> AGENT ADDRESS _ CONTRA @TOR ADDRESS of well/septic
<br /> SUS e. C�vr�d 3((k 0 t- SZ7s- • 6-0(F . ccd€ `E,
<br /> (City,State,Zip) (City,Stat- Zip) ❑ Setbacks
<br /> A,-r(.- J /Ju i 3 rC_ Q ccxi s 6-fi 10.- 1-e+,vrt5 IL_ vood
<br /> PHONE PHONE / ❑ Site Plan approval from
<br /> `
<br /> `f/4 -03 3/0-5 b' Q'a/ 0 90/ applicable township.
<br /> E-MAILADDRESS E-MAILA'DRESS
<br /> /5CvO( c «"C_cH-0//cA ovrvt(eS3 Ca?'I jw1 i r1a7LO—CGr'itc�io/LUiKeje3S_CQ-- -' ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danemLus/)
<br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: ❑ Elevation of property
<br /> ❑ PARCEL t 7Op 3 j, 3 C , frontage drawn to scale.
<br /> NUMBER /
<br /> TOWNSHIP: SECTION:
<br /> /Y- (,tom r� ° 1/a: N 1/41/4: 3w ❑ Driveway permits
<br /> (state,county,town)ADDRESS: c9a/U � � � �/ 3 e,C . C, I ' /1.21--
<br /> VI
<br /> ❑ Sanitary permits
<br /> CSM: LOT SUBDIVIS ON BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION STAFF - „' ,
<br /> PROJECT DESCRIPTION: • a,1./ U • Cp a ,
<br /> ❑This project is a new building or structure.
<br /> ❑ Pet ttt44� Y Fi 4
<br /> This project is an addition/alteration to an existin building or structure. `_ '� A; E;
<br /> SANITARY SERVICE: PERMIT N MBER: ❑ Rural Addressi K
<br /> ❑SEWER ❑SEPTIC one' st � ,.r
<br /> HEIGHT IN FEET: NUMBER•F STORIES: (Not including basement) �, 4
<br /> . ,,-ti:,,,,- , -,4!.:14,4fg-424,y,&:-
<br /> AREA TO NEAREST SQUA"E FOOT: =,, -
<br /> (Outside dimensions including unfinished area,attached ga ages and above grade decks or porches)
<br /> 5 1 P
<br /> BASEMENT 1ST FLOOR: ' � e
<br /> 'TOTAL SQUARE FOOTAGE: A rfit
<br /> 2ND FLOOR: 3RD FLOOR: 7$ ? _ :
<br /> ESTIMATED CONSTRUCTION COST: ♦ _♦ ♦ --► S U UO cc) f gi: g e M
<br /> (Please round to nearest dollar)
<br /> 1. The property is within 300 feet of a stream or 1001 feet from a pond or lake? UYes No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the prop-rty? ❑Yes 6 No ❑Don't know
<br /> 3. Have you talked with the township about your proj:ct and are they in agreement? E Yes ❑No
<br /> 4. Has there been a zoning permit issued for this pro.erty in the past 5 years? ( ,Yes ❑No
<br /> 5. Is this project associated with a rezone/CUP/varia ce (petition/appeal# ) (leave blank if none)
<br /> 6. Is a location survey required? (see reverse) I Yes ❑No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes 0 No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) ■ —► —►
<br /> 545-112(4/08) ',.,
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