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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 /> o5 �Pd 6k054- fit (( Rcck LLc (re&a o � <br /> CI Zoning Stat UP; <br /> OWNER ADDRESS (Number,Street,City,State,1zip) I Deed rlction;CSM <br /> 3 d d Circle= ii0. (t 504 1^.'L 5370 c/ <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 608-576-tf825 g54-t)rtC1S 7 €X,1,00.,Coec <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Sit .Plan including location <br /> AGENT ADDRES CONTRACTOR ADDRESS o ell/septic <br /> (City, <br /> ( Y.State Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plana val from <br /> plic a township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.wri-us/) Elevation of property <br /> PARENT PA EL NUMBER CURRENT ZONING: ACREAGE: P P y <br /> ❑ PARCEL ( /O - 04'. 9�410 ._y C_z 5 frontage drawn to e. <br /> NUMBER V v �J i <br /> TOWNSHIP: SECT} • \ A 1 <br /> 8��ke. �S 14: S 141/4. �w ❑ Drive permits <br /> ADDRESS: (s e,county,town) <br /> /-(3 Zo lloepker Rd t cJi soA >✓-1M- 537©c/ <br /> Cl Sanit permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (P IIC, private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ` o' x 1 D' Pas-F F��t 5+01-0,5 e. (Pohl 5k tot) Z Ig Distt <br /> Lt6his project is a new building or structure. <br /> Permitted use? <br /> ❑This project is an additio Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Ru, ` „It-` ix <br /> ❑SEWER SEPTIC ,------- ...-_._.._.__��-�.____. (11e /,e ing <br /> HEIGHT IN FEET: 1 NUMBER OF STORIES: (Not including basement) , <br /> j1 ❑ `�►eua i, 46[ <br /> e-� <br /> AREA TO NEAREST SQUARE FOOT: :'' - , <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ a.e a e R a f <br /> 3 600 ,j, TOTAL SQUARE FOOTAGE: 4, (slopes • ' a <br /> fult ss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ^ <br /> ❑ ReviewL ofi- t#tvey- - <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ and a ,t to �� <br /> (Please round to nearest dollar) -000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El/No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑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 none) <br /> 6. Is a location survey required? (see reverse) Li Yes No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes L No <br /> t, g . APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► —► <br />