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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWN49w?a R)IAME CUSTOMER TO PROVIDE <br /> OWN `(;- k� �_-7 er Q/ <br /> DRESS (Numbe _ reet,City,State, ) �1 ❑ Zoning Status; CUP; <br /> 7 0214E 4./kt 2 Deed Restriction; CSM <br /> HOME PHONE CELL PH NE E-MAILADDR1/ s�JS�° Variance(# ) <br /> Zo3 - c T f 56-u- e ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N E CON ACTOR NAME <br /> d'GENT- 's r rent ,e - ❑ Site Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> 0✓ - / ( r !r <br /> (City,■• e,Zip) <br /> (City,State,Zip) /t C! ❑ Setbacks <br /> PHONE //' / S SS- <br /> OQ .c,�! PHONE /c I r ❑ Site Plan approval from <br /> U z- 66 S� applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRFFSS <br /> I' t� d Ai (fl l Pc ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wri-us/) <br /> PA� �j PARCEL NUMBER: CURRENT ZO ING) ACREAGE: ❑ Elevation of property <br /> ❑ NN MB`ER 3`�Q7OX., 03-.13Ltri?d O N /t Li frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 0 7 /77t car icM . 0 / 1/4: S k1 1441/4; 5E ❑ Driveway permits <br /> (state,county,to <br /> wn)ADDRESS <br /> 779 8e S r akP U(//ern k); �3C3 ❑ Sanitary p ermits CSM: LO SUBDIVISION BLOCK/LOT <br /> if 6 her z (P (public, private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: AT FF'REVIEIIIt <br /> 5/6(I/ k)P - e °U ctrti Di t <br /> ❑ his project is a new building or str ture. <br /> This project is an addition/alteration to an existing building or structure. 0 Pelrrliltteti <br /> SANITARY SERVICE: PEF�MIT NUMBER: ❑ Rl6l f�lrs <br /> ❑SEWER ❑SEPTIC ( ice; <br /> HEIGHT IN F4ET: NUMBER OF STORIES: (Not including basement) 1 <br /> (�3( ❑ etlr'3rit (OS3 r tf <br /> AREA TO NEAREST SQUARE FOOT: ` 5f 4talid re-TI <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: mga .�.. f <br /> j, TOTAL SQUARE FOOTAGE: 4, ''� i e a c <br /> 2ND FLOOR: 6c s <br /> 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: / 1 0,14*,: ', *--- f <br /> (Please round to nearest dollar) "∎ '-∎ '■ -∎ —► -■ 3r`' 0 0` e, <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? ID Yes I -No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes t ,/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 bla k if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes i[�lo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes I o <br /> / , d C3 APPLICATION MUST BE SIGNED <br /> 545-112(erg) �� (Continue on Back) —► <br />