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'-7 -1 A <br /> ZONING PERMIT APPLICATION www.countyofdane. om SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> U c +S e. -sWICM ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State, ) Deed Restriction;CSM <br /> G iLlbu Y <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 263 — 2122-7 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRAC OR NAME <br /> ' _I (°bti1 c SzhiSIe-I C pv_i covre SfetJ —$LLC Li Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,zip) ❑ Setbacks <br /> w NA G-3. 5359/1 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 666---eli 7 _ 2 applicable township. <br /> E-MAIL ADDRESS E-MAIL AD RESS <br /> w,���N oL C�f/� �,A-16- <br /> CI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daneawLus/) <br /> PARENT PARCEL NUMBER: CURRENT'ONING: ACREAGE: CI EleVatlOn of property <br /> ❑ PARCEL 5 R/ _ 7 �'1 frontage drawn to scale. <br /> NUMBER LJS( cl 3 0 a %° .°� / _( <br /> TOWNSHIP: SE ._ . <br /> yJ 1/41/4:N ❑ Driveway permits <br /> �,°e So ,,� 1/4: !� r state, • n ,town) <br /> ADDRESS: <br /> S I CJ/-1 /� <br /> ' J CI Sanitary permits 1 <br /> CSM: LOT BLOCK/LOT <br /> � G / ' ) (public,private) Q, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW,' <br /> PROJECT DESCRIPTION: / �j ' <br /> RAit( 1 I \ b\ N / )9.-\ Zoning Dist' ' . <br /> ❑This project is a new building or structure. <br /> Permitted Use? <br /> a-This project is an addition/alteration to an existing building or structure. <br /> ❑ Rural Address'-f <br /> SANITARY SERVICE: ,may� PERMIT NUMBER: / { ,E <br /> ❑SEWER 0-SEPTIC (new/ex ng/ '�' <br /> HEIGHT IN FEET: I NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetlan4WF*!IN <br /> `�areland chment)` <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) la <br /> BASEMENT 1ST FL R. <br /> 1 .- 4, TOTAL SQUARE FOOTAGE: l /aacss i - a 7 <br /> 2ND FLOOR: 3RD FLOOR: <br /> s <br /> Review Location trvgy <br /> ESTIMATED CONSTRUCTION COST: $ 3� and Ta le . <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 Pt No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Ye :No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? <br /> CI <br /> 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) -o. ■ -+ <br /> 545-112(4/08) <br />