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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME A A <br /> / g IC/1�4eL �,s <br /> 52(Zoning Status;CUP; Wi <br /> OWNER ADDRESS (Number,Street.City,St41c,Zip) Deed Restriction;CSM 35Z` 3)L -/ZF/t -J m <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 62 DS 7L-4-/-5(.36 Co O9 333-1Z55 Dia'J S le 6-1C" G MAt 4. < Cos`'-` Ya Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ^' >0 NI LL1µ^Bd7L- A Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3y D�o•� fib r 373 0/5-0/5-P <br /> (City.State,Zip) (City,State,Zip) a Setbacks (P <br /> L/a/■,gpv c-, (A-) I S35Z3 <br /> IL PHONE PHONE Site Plan approval from/ <br /> G o a 76,1-S Z Z Z applicable township. / <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wri.us/) Elevation of ro ert <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P Y <br /> U /1 PARCEL g a frontage drawn to scale. <br /> NUMBER � � � <br /> TOWNSHIP P•� SECTION: DrIVeWa elfTll / <br /> l-)E 1/a: 1/414: yp <br /> ADDRESS: (state,county <br /> S-Z q Dc--En-r t ELF ,g( <br /> C <br /> 41/ <br /> SM: LOT SUBDIVISION BLOCK/LOT ,'y�Sanitary pe��•'s <br /> 11 3 cp s 2-- (public, . - <br /> PROPOSED PROJECT INFORMATION STAFF REV <br /> PROJECT DESCRIPTION: 2, <br /> PoLE- Zoning Zoning D ist ,'"_r <br /> This project is a new building or structure. <br /> Permitted Use? <br /> !'4 ; <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Rtirai "" � '' <br /> ❑SEWER ❑SEPTIC ( <br /> neW/.r p19 4�' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> �Z / Wetlardt ain/ <br /> Shorelan€( (Aitad#tment)' <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: t a s ,�-_ <br /> /91 ! 4, TOTAL SQUARE FOOTAGE: j � s d s i , , <br /> / <br /> 2ND FLOOR: 3RD FLOOR: /' . „:--- 04.14, <br /> V z <br /> / `/ Review Locati ” urve <br /> ESTIMATED CONSTRUCTION COST: yI J /� <br /> (Please dollar) ♦ -► ♦ -� -� -� li Z 7 s 1 O ittl avalabte t�tls. 111+r++ /V <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? ❑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 /> 545-112(4/08) <br /> (Continue on Back) -+ -+ --P <br />