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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App <br /> PROPERTY OWNER INFORMATION CUS OMER TO PROVIDE <br /> OWNER NAME <br /> �,�^ <br /> r Y`Os \ (t/NIL le 'oning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1 eed L ik 0 'P�ec,JiNn V G,11�e�, e ex , B�aL -l:oc � W\ aria Rees fiction;CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 53.s lam' (# ) <br /> 6 0g-767450)6 o V--6,,77-bS9 9. S' a Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION ndincludesdimensions <br /> AGENT NAME CONTRACTOR NAME <br /> �0. G5 0 v.)rer S' a Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ e Pla pproval from <br /> p • ble township. <br /> E-MAIL•sDRESS E-MAIL ADDRESS <br /> i loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http //accessdane.co.dane.vwi us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONIN • •CREAGE: JElevationofproperty <br /> ❑NU <br /> NUMBER <br /> ©'.d6 O 9 X94 41 D IR 14 -4 3 Q30I o'�O. 9 frontage drawn t le. <br /> TOWNSHIP: 1 i SECTION: / <br /> V -Cr 1M 0" 9 1 1/4: (s+W 1/4%/4: NW ❑Drlvew ermits <br /> ADDRESS: (s ,county,to <br /> t-'y''O p lk°'S un4 \O S,e IzeX ` ❑Sanita ermits <br /> CSM: L 6°I LOT I SUBDNISION BLOCK/LOT . lc,private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 3 c' a X`{S' P O 1e Sol'4N /8 ;.1-■o n W g It) <br /> 3110f/ 6 ning District <br /> . ❑This project is a new building or structure. <br /> Permitted Use? <br /> IZIThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: CI t Rural ' ' 701 <br /> PEWER PEPTIC O 00 b (new 'xisting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 3 1 ❑ Wetla oodplain/ <br /> AREA TO NEAREST SQUARE FOOT: 135 a S land (��t�chcrie(t� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �.1\� l <br /> ❑ ErosionControl permitC <br /> BASEMENT: 1ST FLOOR: /.35 D + TOTAL SQUARE FOOTAGE: j ( pes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 135 0 Iling/access) kit\ <br /> Review Location Survey <br /> rvvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 6 r)00 . 0 6 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes laJo JDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Jo Jon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? LYes Dlo <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 lJo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes [p io <br /> 4 isi , — <br />