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ll t '` .:SUPROMENTrto Neb App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com - <br /> PROPERTY OWNERtINFORMATION t. �,�-_;. ._ rz ._ Ai'.:,:_ r} `>>: Z CUSTOMER TO PROVIDE • <br /> OWNER NAME \ . <br /> R'`^'� J L Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 0 q 8 5 t{L-,' P�.� fl1L - t'''t AF-3.1-4/h- ,vs-' ( -5-3-53- 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS - <br /> ()8 (o S5 33( (036 CAA Sao ( 6af a -2 (an) Sc�.. e Lff 11.1 67‘.' n Site a -awn to scale <br /> �AGENTTINFORMATIO�I ` w � . ti ; , (CONTRACTOR`1NP R I�/�TION, j {- and in udes dimensions <br /> AGENT NAME 'CONTRACTOR NAME ' <br /> n Site Pla Including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of w eptic <br /> (City,State,Zip) (City,State,Zip) ❑Setb K <br /> PHONE PHONE ❑Site P •04 • I from <br /> - appl• ab • ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS - • <br /> ❑ Floor plan to ale <br /> PROPERTY/LOCATION_INFORMAT(OMr'(http%laccessdane,co,dane:vlr.us!)r ; ' - ❑Elevation of property <br /> PARENT PARCEL NUMBER: .- CURRENT ZONING: ACREAGE: <br /> 0 NUMBER U tJ 1 Z - Z v( -U S5°_1 - 3 - a, S frontage drawn to scale. <br /> TOWNSHIP: - SECTION: �� <br /> W\l O r■ pr 2 I : r!L Ihih: /,l W n <br /> ❑ Driveway permits / f(/ <br /> ADDRESS: I (state, county, town) <br /> gl e S 1'1t—11,9ri cx- - Sanita ,• t^t C <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ A <br /> 6' ( 6.5 - ' (publi • • a - <br /> PROPOSED PROJECT-INFORMATION '� '�"'° <br /> PROJECT DESCRIPTION: z'4t� -F�' <br /> . ❑This project is a new building or,structure. atE; ml ®_,`s 1:`4 `� <br /> nThis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> EWER 0..EPTIC T? <br /> E <br /> HEIGHT IN FE NUMBER OF STORIES: includin basement <br /> . . . k\ \ ' ' <br /> e.tTapt.,e e It1 -gin+- <br /> ARE 0 NEAREST SQUARE FOOT ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) m D i e <br /> BASEMENT 1ST FLOOR; ' _ , -° e—t <br /> • • 1. ( Z J , TOTAL SQUARE FOOTAGE 4, r .�"' 4::0,,,,,,-7,-±� <br /> 2ND FLOOR: 3RD FLOOR: 1 1p _c `°'111" ' _-. :„1 <br /> ,= _4 � . <br /> . i 4a° pl.i-4,--ESTIMATED CONSTRUCTION COST: "'1 Fym P; <br /> (Please round to nearest dollar) -4* '-* "'3' ♦ -" '� ( I t 00� � 3 =. V'' ", <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes ,]No.' nDon't-know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No .['Don't know - <br /> 3. Have you talked with the township about your project and are they in agreement? esNo. <br /> 4. Has.there been a zoning permit issued for this property in the past 5 years? es NO • <br /> _ 9P P P �Y • P Y �. � - . . <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) es QNo ❑Don't know <br /> 7. Is this to correct.a violation? es , No . <br /> APPLICATION MUST BE SIGNED <br /> • • (Continue on Back) -+. -I -is <br /> 545-112{4/O8) . - <br />