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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER:INFORMATION,a , _ ' ice.,^ < P1'2'-V---$
<br /> OWNER ' ``'",,;,�"'�` '�,': , CUSTOMER TO PROVIDE
<br /> �% �fJ / [9QY7' Wing Status;CUP;
<br /> OWN//ADDRESS (N er, reel,City, tate, Deed Restriction;CSM
<br /> 7 �Q3 tc kle�tate,
<br /> Ci'd eG e ��rl,t
<br /> Variance(# )
<br /> HOME PHONE j CELL PHONE E-MAIL ADDRESS
<br /> e 9- ✓ 2?. ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION:-,. CONTRACTOR INFORMATION ' ,•
<br /> ,. .H,f and includes dimensions
<br /> AGENT NA E CONTRACT' AME
<br /> (e -e _,,,,A __ - k z �{ ¢ Z ❑ Site Plan including location
<br /> AGENT AD' ESS CO TRACTO'ADDR f/
<br /> ESS of well/septic
<br /> J _ I i.. _!t:5-b.
<br /> f
<br /> ( S- ip) (City,State,Zip) << CI Setbacks
<br /> L� U. w! 53�
<br /> PHONE PHONE <c • ❑ Site Plan approval from
<br /> to D - (S-92- Cr applicable township:
<br /> -MAIL ADDRESS E-MAIL ADDRESS
<br /> ,, . )Ye li S� ,Ci ❑ Floor plans to scale
<br /> PROPERTY/LOCATION;INFORMATION '.(http:llaccessdane.co.dane.wi.usn
<br /> ❑ Elevation of property
<br /> rty PARENT PARCEL NUMBER: CURRE ZO/INGA ACREAGE:
<br /> ❑ frontage drawn to sca le.
<br /> le.NUM ER Q/0 71/ Jul eief S d J
<br /> TOWNSHIP: SECTION:
<br /> ree"ri .# ( 7dc /U /: F 1/4/: =.1 ay rmit
<br /> s
<br /> (state ty,tow
<br /> n)ARESS:
<br /> Y//e3 &'14 Gt / eermu¢e 17;e7 -e GUa mits CSM: Q SU:•IVISIO BLOCK/LOT (pu rivate)
<br /> PROPOSED PROJECT INFORMATION,
<br /> PROJECT DESCRIPTION: iv
<br /> °
<br /> 1';: .S / , ' ¢ ,,;ar�fa jR-L� ,z
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<br /> ❑This project is a new building or structure. - '
<br /> This project is an addition/alteration to an existing building or structure. ' s� -
<br /> SANITARY SERVICE: PERMIT NUMBER: . , Fr3Y�-'irY a k , ,
<br /> ❑S ❑SEPTIC s- � �a k ,- ``, -
<br /> HEIGHT IN FEET A NUMBER OF STORIES: (Not including basement) LZ.L,., -,-'..
<br /> � 5-
<br /> J�" r 411:i° E f•AREA TO NEAREST SQUARE FOOT: p£
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , 4i
<br /> BASEMENT: 1ST FLOOR: y
<br /> , ' �4, TOTAL SQUARE FOOTAGE: 4, a E k
<br /> 2ND FLOOR: 3RD FLOOR: �. � )
<br /> (NZ"'1,4'746 r
<br /> ESTIMATED CONSTRUCTION COST: -
<br /> (Please round to nearest dollar) "* "� fi - t , T
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes iiJlo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes c'No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Y
<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) DYes ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -i -► -0
<br /> 545-112(4/08)
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