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,SUPPLEMENT-toWeb-App#
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY OWNER;.INFORMATION'. z,;.- _ z= ,.1, 'u 40? . ,, =._:'t. r CUSTOMER TO PROVIDE
<br /> OWNER NA ' , I
<br /> ike E I Ch l! en (Zoning Status;CUP;
<br /> OWN R DD ESS (Nu bi. reef, ity,State,Zip g
<br /> 11 �,/ Deed Restriction;CSM
<br /> Q�� 47 'Y/00 U Variance(# )
<br /> OM PH0NE CELL PHONE E- •ILADD� SS
<br /> P`_ , ` • i / "/ �'2 ,II 4 • I ',I: 1 aA6te, LO 44 Site Plan drawn to scale
<br /> AGENT INFORMATION ,:'i CONTRACTOR INFORMATION - /and includes dimensions
<br /> AGE AME yf CO -•CTOR%A E �,.,1
<br /> �ail7 /'/d�/ /AP /'z/DT/ 6012451 Site Plan including location
<br /> A TADDRES C• RACTOR A2.4221 ESS of well/septic anai ecil
<br /> (City, Zip)
<br /> C .� 7 (cH i ty ' ip) l
<br /> ISetbacks
<br /> at-5h al/ teif 5,5v ia- a// kiZ 453� ISite Plan
<br /> approval from 655=495 7 PN F
<br /> �539— .2,57 pplicable township:
<br /> E-MAIL ADDRESS E-M ADDRESS ,ter,Vi /l071/, �;,,,/Can- �yi
<br /> Ai,72/ a q,0.I 615h1 Di F or plans to scale
<br /> PROPERTY/LOCATION INFORMATION '::(http:1/accessdane.co.dane.wi.usn Elevation of property
<br /> PARENT PARCEL NUMBER: CURRE TZO IN!: ACREAGE: s' p P rty
<br /> PARCEL �/ // i/ 7 O frontage drawn to scale.
<br /> '(y� ❑ NUMBER bJV •I/Z"-ow!'/.' AI ,.16 ,
<br /> TOWNSHIP SECTION:
<br /> h/ q , , , y ) /r Driveway permits
<br /> ��° /y, /4: /j/�/ /./4: /Y,C / (state,county,tow
<br /> ADDRE S:
<br /> Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> D , (public,private) )
<br /> PROPOSED PROJECT INFORMATION. fir I
<br /> PROJECT DESC TION: ��•
<br /> Kezi) 1/01/5e ,,,J=,:arz-A:pliet1:54,, ,' -.: '::,/i-;.- A
<br /> r� . 'act�-� t�
<br /> ' This project is a new building or structure. E, fr -:-.,t,,,'
<br /> r
<br /> ❑This project is an addition/alteration to an existing building or structure. 4 t� 5P 4-
<br /> SANITARY SERVICE: PERMIT NUMBER: 4 0,1 °'rS :`` `
<br /> ❑SEWER iSr SEPTICgi
<br /> HEIGHT IN FEET NUMBER 0 STORIES: (Not including basement) TMa
<br /> AREA TO NEAREST SQUARE FOOT: - ,�� �' f
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) k ''=
<br /> BASEMENT 1 ST FLOOR: ,•:.,-,-'1„,.,,' ®a �410' r r-
<br /> h TOTAL SQUARE FOOTAGE: 4, i., '�'�' wat l
<br /> 2ND FLOOR: 3RD FL•.OR: /
<br /> ESTIMATED CONSTRUCTION COST: ♦ -•► _n. --► -•► ♦ ��� q i a ,ij . t l
<br /> (Please round to nearest dollar) ii rt e
<br /> coo`) — 01 e'l y
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ��❑I�Y//es C`�1 o LI Don't know
<br /> 2. Is there a wetland or floodplain on or near the property?.41......0.h..p or ... ales ❑No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreementlErYes ❑NN
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,9 ❑Yes L`7No
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#fe��(/ ) (leave blank if none)
<br /> 6. Is a location survey required? (see reverse) ❑Yes ,C' No ❑Don't know
<br /> 7. Is this to correct a violation? LI Yes 'No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -► -► -►
<br /> 545-112(4/013)
<br /> 4-
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