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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Wel>•App#.
<br /> PROPERTY OWNER;:INFORMATION z; _ _ ? ' y� :, ,
<br /> OWNER NAME ��° '�� `'"' ` "� ° CUSTOMER TO PROVIDE
<br /> \' - 1/61/1/"EZ- OAABS oning Status;CUP;
<br /> OWNER O DRESS (Numb r,Street,City,State,Zip) eed Restriction;CSM
<br /> �/0 � Y b A/ C C . E (3,01/6-1 Ll�s 5a5;029- Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> 408'.,41„. 5%'S76 - 7 , , 5--%572, /�•c DCLjSETS - 6- •A. ' r Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION: %',l and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> PI- ite Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (city,State,Zip) (City,State,Zip) 11 Setbacks
<br /> PHONE PHONE • ❑ Site n roval from
<br /> ap ' township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> ❑ Fl s o scale
<br /> PROPERTY/LOCATION;INFORMATION`::(http:llaccessdane.co:dane.wi.usn; Elevation of
<br /> PARENT PARCEL NUMBER: c CURRENT ZONING: ACREAGE: property
<br /> P rtY
<br /> VI NUMBER OtOI'01a` L r,rOo� A) 54 1.1 frontage drawn to scale.
<br /> TOWNSHIP: Q SECTION:
<br /> V.E r.ri 5pP/44S / %:T lot ,/41/4:R,S j C ❑ Drive rmits
<br /> ADDRESS: ( e,c nty,town)
<br /> 31)$Q 1-1-wt 3j) •- ' tIE j O)L w 635x7 ❑ Sani ermits •
<br /> CSM: LOT SUBDIVISI BLOCK/LOT
<br /> (publt ,p • ate)
<br /> PROPOSED PROJECT INFORMATION, <
<br /> PROJECT DESCRIPTION: /1 TA }r a
<br /> XThis project is a new building or structure. � � ;
<br /> ❑This project is an addition/alteration to an existing building or structure. ;= -,..W' - °'
<br /> SANITARY SERVICE: PERMIT NUMBER: 6 e a `t T
<br /> ❑SEWER SEPTIC 'z'� �' a vm;4s- - Et-,,,,ii
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) €.. ,
<br /> 4'2 TY , i,
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � i,�,
<br /> °®r fie, , ' 'ra
<br /> BASEMENT: 1ST FLOOR: , ,
<br /> 19'IO I!'4 10 4, TOTAL SQUARE FOOTAGE: 4, :'; �. ,A`::'
<br /> ,
<br /> , i lift" °-' w
<br /> 2MB-FE69R!• 3RD FLOOR: �5-eob
<br /> t k15 ,_,Ff
<br /> ESTIMATED ED CONSI�UCTION COST: FT 3 �` « � ,
<br /> (Please round to nearest dollar) -+ .+ -, - - "'" $ 016;000, -F ' ®t, �- 7:-
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes KNo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? 4es ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes iG
<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 ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -► -► -I.
<br /> 545-112(4/08)
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