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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#
<br /> y PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> 1 - OWNER NAME
<br /> Pe, ems' / ' PE.;,.-,e(I ❑ Zoning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> 'J (,//�ti•-) PGA Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> Co og-695-v (4q 1, /l 0 ,,,,, ,w.., )d Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> S-f vim- j"tiQ/n/A _ ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> /3t// ;jl-
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wri.tusl)
<br /> PARENT PARCEL NUMBER: CURRENT ONIN ACREAGE: ❑ Elevation of property
<br /> ❑ NUMBER O c/b —0 6 Z-30?c -O �-//�k /,`l frontage drawn to scale.
<br /> TOWNSHIP: SE ON:
<br /> - v
<br /> TOWNSHIP:
<br /> ,,/ U60 1/: /UW 1/a'/: A) ❑ Driveway permits
<br /> ADDRESS:
<br /> _ (state,county,town)
<br /> 6, �/ �� )< i ❑ Sanitary permits
<br /> CSM: LOT J g SUBDIVISION / S'' add BLOCK/LOT
<br /> '°I -eca IA'ea) (public, private)
<br /> tv)PROPOSED PROJECT INFORMATION STAFF-REVIEW ,v,'
<br /> PROJECT DESCRIPTION: M 1
<br /> e G K �- c O'O C,�2 (�cc d CI Zoning aster n-
<br /> ❑This project is a new building or structure.
<br /> ❑ Permitted lIse? .
<br /> AThis project is an addition/alteration to an existing building or structure.
<br /> SANITARY S RVICE: PERMIT NUMBER: /❑ Rtiraf Address ��y
<br /> SEWER ❑SEPTIC (new/exing) 4
<br /> HEIG1IN FEET: NUMBER OF STORIES: (Not including basement) ' F
<br /> 3 U ❑ WetIa ., o+ a
<br /> Sfioretatld � ent)
<br /> AREA TO NEAREST SQUARE FOOT: '!
<br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches)
<br /> �
<br /> BASEMENT: 1ST FLOOR: � !,p g v
<br /> 4 TOTAL SQUARE FOOTAGE 1 ,4d ` ' R, ,
<br /> �r 00:04,14::,
<br /> t"i3 es )
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> Rev ew ,xocatfi 3li.
<br /> ESTIMATED CONSTRUCTION COST: $ 07,700 607 Ra yi � 5-
<br /> (Please round to nearest dollar) ♦ -0 ♦ ♦ ♦ ♦ ,.::::4• 1',".;,,,,.-
<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? A Yes ❑No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes )I 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 A No
<br /> ©,c90
<br /> �` c C APPLICATION MUST BE SIGNED
<br /> 545-112(mo) �/]�©O (Continue on Back) ♦ -� -►
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