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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 3 R <br /> A-IFA <br /> ' ail b y Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ( Deed Restriction;CSM <br /> 117 3 ton n of C i2/ S7Lou�h pki, 6t/-1 ---C3-1?9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRES <br /> 6C F- 77-4 067 66e-zi ill- 6 46 0 iz ;at). LL-' o e A+4■ rt e± `►c Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME , <br /> `TA/Site P an•• luding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS •f ri j/- •ti y <br /> (City,State,Zip) (City,State,Zip) g Setbacks 3 14/15/l/ b <br /> PHONE PHONE listSite Plan approval from A 74 <br /> applicable township. /r 1/ <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daneawLus/) !4 Elevation of property <br /> PARENT PAR LNUMB R r CURRENT ZONING: ACREAGE P P y <br /> PARCEL ski/ f ���� _� �� f frontage drawn to scale. <br /> NUMBER (� / <br /> TOWNSHIP: SECTION:// �/' <br /> 5 /r 14: !T ' 141/4: ADriveway permit <br /> ADDRESS: (state,county own' <br /> C-✓�-C., G s 4 .b D v-, <br /> Sanitary pe its <br /> CSM: gr LOT SUBDIVISION BLOCK/LOT (publi <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW 4:c <br /> PROJECT DESCRIPTION://1 1 2 � 6 F C tv i_' r ,/ ..,.../ <br /> ) ///��� //�/,(�- ontng Dish <br /> ❑This project is a new building or structure. P rmitted se? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: RUraf A.,-• <br /> ❑SEWER SEPTIC (ne -. iII• <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) Wetla n oo n/6" l eland ,attachment) ,,�� <br /> AREA TO NEAREST SQUARE FOOT: , <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) `t ' ' <br /> BASEMENT: 1ST FLOOR: •11 <br /> / f 4, TOTAL SQUARE FOOTAGE: 1 #' r, ':'. ,.-,y( <br /> filling/access) " <br /> 2ND FLOOR: 3RD FLOOR: `‘ r ' <br /> ESTIMATED CONSTRUCTION COST / Q ey -L - <br /> -► -� -► -► -► -♦ and available�ons <br /> (Please round to nearest dollar) 3 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -► <br /> 545-112(4/08) <br />