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Q / <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME (/VI 'tom�F,/ S<< b C l y❑ y('ni ng Status; CUP; <br /> OWNER ADDRESS Number,Stree City,State,; )t Deed Restriction; CSM <br /> l 3 Y ' ��rlTy'^�.c f cL Ov t'41041 tell S3575- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL A RESS <br /> - Ck k — a. S' Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME C NTRA QRRNAME <br /> v LON 1 K-(( ; 46-. ja. ( V i Cc.) �c , .Z- c ❑ Site Plan including locatioIr� . <br /> AGENT ADDRESS CONTRACTOR ADDRESS •f well/septic ______.__ <br /> '? s- 7w :k Vic l(cY i ct 4/ 5— 7.--;k.,3 It 5-F ,� �' -- <br /> (City,State,Zip) / (City,State Zip) / / C liJ'Setbacks <br /> /14 :1d le -t'i.-- (PT' 515-4 3 M` /4-4". /.Cn d 4/- - 3- - <br /> PHONE G PHON g - O e Plan royal from <br /> eo D - Ala — 3? 7 �l 7 o -7 ap nship. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> lour plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) i levation of prop <br /> PARENT PARCEL NUMBER: CURREN ZON ACREAGE: <br /> ❑ PARCEBER iL OS q - CA .-a-5/(M 1� / frontage drawn to scale. <br /> NUM _.- <br /> TOWNSHIP: SECTI <br /> 01\e r, —' 1%: Nr tJ 1/41/4: ,N IN) Dr' a e`rmits <br /> ADDRESS: nty,town) <br /> n' permits <br /> CSM: LOT SU DI I ION BLOCK O vate) <br /> PROPOSED PROJECT INFORMATION S' AFF.tEVIEvi( <br /> PROJECT DFSCRIPTION: <br /> t <br /> Q1dl ti re e s D-- A <br /> d K f Ching QlStrtCt r <br /> ❑This project is a new building or structure. rmttteci Uses <br /> ,afhis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ur r4 .., <br /> ❑SEWER . ��6/EPTIC '(ne existing '° t <br /> g <br /> er <br /> HEIGHT IN FEET: /� NUMBER OF STORIES: (Not including basement) ❑ Wetla • i I <br /> 4.e f S 4� Shor 'd (attach ent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Eros Co ol€ ermit ` <br /> BASEMENT: 1ST FLOOR: SIO eS<®I Cbarice ' <br /> '�_ 1 L+- T 4, TOTAL SQUARE FOOTAGE: y (,f p <br /> lJ d� ) <br /> 2ND FLOOR: 3RD FLOOR: 5 f " S <br /> Review Lo *IiiSU J <br /> ESTIMATED CONSTRUCTION COST: ^) 3`'/q and avat(at�Ce°'opttons <br /> (Please round to nearest dollar) "� ♦ ♦ ♦ ♦ / / ',,,,� ..,` <br /> IN) <br /> P <br /> 1. The property e is within 300 feet of a stream or 1000 feet from a pond or lake? II Yes 'No ❑Don't know � <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ZtNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes grNo <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 ErI C o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,No <br /> A MUD <br /> (Continue APPLIC on TION Back)ST BE►— -4 SIGNE► <br /> — <br /> 54e-112(4/08) <br />