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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE, <br /> OWNER NAME <br /> elei2q ' C�j� 0 4 Zoning Status;CUP; <br /> OWN R ADDR SS (Numbe� reet,City,sta e,zp) 5 Deed Restriction;CSM <br /> 01W1'4- <br /> W, () (A I e p L u 12 6i 1 p ke, W) (7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 5 )-ZU of - r.o. Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR 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 30/i 0 ;51? <br /> PHONE PHONE ;Site Plan approval from t . <br /> applicable township. N T <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ►Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danevwLus/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P dy <br /> PARCEL Oct t pp c frontage drawn to scale. <br /> NUMBER l �� 1 3 0�b 4 7 g / <br /> TOWNSHIP: SE I :1-01 /2 II L`- ,/ / /fj <br /> ��'15 TO - 1/4: AAA.) of 1/41/4:N e- 1 Driveway permg C4-- <br /> ADO ESS: (state,county, <br /> �i�y U k °`e7` Sanitary ■ermitss <br /> CSM: LOT SUBDIVISION )i-Q hk BLOCK/LOT /► l V <br /> 76. Pg►k)/2)-e U e.---147 <br /> public, <br /> PROPOSED PROJECT INFORMATION STAFF REV <br /> PROJECT DESCRIPTION: 11/ _/ <br /> �� X Oic1 S 6C �v 0 I Zoning District , <br /> ❑This project is a new building or structure. '� 5 ? <br /> ,Permit Use 7; Sill <br /> ®This project is an addition/alteration to an existing building or structure. `DECK v 1 <br /> r <br /> SANITARY SERVICE: II�� PERMIT NUMBER: Rtilr - ` <br /> ❑SEWER IIr3.SEPTIC (Re tstifing) - ;, <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ri� <br /> �� Vetlap���a�, grtJ <br /> _ oreland( ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ! ��e®,, ff R a n 1 a4 <br /> BASEMENT 1ST FLOOR: <br /> I 1 TOTAL SQUARE FOOTAGE: , . a r� •` <br /> 2ND FLOOR: 3RD FLOOR: <br /> `)mac 3 <br /> ESTIMATED CONSTRUCTION COST: � 'v1rrW �� <br /> (Please round to nearest dollar) $ I t,0 0. 6 BR 3 Tct1� . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes t No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 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 ®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) ❑Yes IS No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Q No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ ■ —► <br /> 545-112(4ro6) <br />