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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER)1"E <br /> / °YI J t Y U I l Ole r� <br /> Z"---)'I Zoning Status; CUP; -- <br /> OWNER ADDRESS (Number,Strry e Cit ,State,Zip) Deed Restriction;CSM <br /> (HZO)Ni / o�/' y ,9r . �L--111 -�L L Variance(# ) <br /> H� E CELL PHONE /l E-MAIL ADDRESS I <br /> a s_ ? -7 7 J E�ahe f/e o ��kP cg- d3 •h� Site Plan drawn to scale■ <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> C.JG[)/e/he 4 ,Q,-' P,-e,2 /e , 2v/ 1,/e/15 ESite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic / <br /> /Pa; N /S //'d4 iOt , fv ti l /'d .0r 15 /o ff <br /> (City,State,Zip) (City,State,Zip) / ( I�I Setbacks 3 / <br /> ( y / i <br /> 61)&41�61,�°e �/ S 5�/ G)1i! 14")a---k-e' 641/ X35-72 <br /> PHONE G PHONE � Site Plan approval fro ///4_ <br /> 4'D j — 0 1/91- 7-2O w er — / % G "7 26 applicable township. <br /> E-MAIL ADDRESS _ / E-MAIL ADDRESS / /(= / <br /> J e�lVt, , o c lam ; ,V a✓I e �r 6-G / , els,he- Floor plans to scale / / <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) 1/ 1 <br /> PARENT PARCEL NUMBER: CURREAONN7 I ACREAGE: k Elevation of property <br /> ❑PARCEL i�q�� _ /_ /aa ? l� _ frontage drawn to scale. <br /> NUMBER J _ <br /> TOWNSHIP. 1 SECTION: <br /> / .5 ( �/ 14: 1/41/4: �.riveway permit �/^ A <br /> ADDRESS: ,Z ^ �4 I v ; C i C <br /> (state,count y,4101 <br /> , 1� <br /> CSM: `� LOT p', BDIVISION BLOCK/LOT jg Sanitary permits i /, ?�/ <br /> (public,private) (� i <br /> brand vie6J 143, <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> tECT / <br /> 3J 1-k1 l t_ -LLi ,- ! ,//-i 4-( `Q G XLZoning District A --.1 <br /> his project is a new building or structure. permitted Use? off <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: d/i R Address ,,.. 2 tt: <br /> FIEWER IC 3Z a 3 V 1F� /existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) /il <br /> 1 41 Wetland/Floodplain/ <br /> horeland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) /4 <br /> BASEME : 1ST FLOOR: EcoslonContr0l permit 4,4y 03 1 TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1/7 j10 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: / and available options. v Y <br /> (Please round to nearest dollar) ♦ -+ ♦ -► ♦ ♦ $v 06, 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves G• o EDon't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ri, o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? uYes ['No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Des ❑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) -► <br /> 545-112(4/08) <br />