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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU•TOMER TO PROVIDE <br /> OWNER NAME <br /> /' 4 ! �"/ �� // <br /> ' f o 4(-S II Z',ning Status; CUP; <br /> OWNER ADDRESS (Number,Street ply,State,z' 11 eed Restriction; CSM <br /> /gw TIe`Yv f / 4>� ,C 313 ariance(# ) <br /> HOME PHONE CELL P ONE E-MAIL. RESS <br /> t5D D S.--?Y1( C�Dz3—.)0).c.--9?// on -.11P� //14:24,(4/:, •CO P ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION P and includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> Af/- ice- 7.14.~ ,f/d, ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> // 3 r e1�l7a-,,e AG%t <br /> (City,State,Zip) (city, o q_Setbacks <br /> 4)/*h / 5 3.r./e( <br /> PHONE PHO [Site P approval from <br /> p/S,3-",: c?S" )_1// ap cable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> d' t e lQ Out. < „MI oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER. �� CURRENT IINNG: ACREAGE: I levation of property <br /> 0 PACER 7 (I ^ S 0U ",64, �.f) 7 frontage drawn to scale. <br /> TOWNSHIP: SE ` l e <br /> A6t/ 0 '/4: ��/" '/a'/4: -- Driveway perm <br /> ADDRESS: (state,coun ,town <br /> I4,-/t/1 i i'1 rII j/-0 �y Sanitary permits <br /> CSM: LOT SUBDIVISION /4 /�� (!BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ktv s-/-r e-A 1 .., 'rig District <br /> . This project is a new building or structure. ,e (_4q_ r01 C in it "emitted Use? <br /> [This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT N MBER: Q ® " Atldr�ss <br /> EWER EPTIC 1 ^3 '-:7 O ^ ©0 / / 'xiS ) <br /> HEIGHT IN FEET: , NUMBER OF STORIES: (Not induding basement) <br /> ❑ Wetland/F in/ <br /> AREA TO NEAREST SQUARE FOOT: (a c.. t) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) `u Eros. <br /> BASEMENT: 1ST FLOOR t � r <br /> 7 j� / i Q ? ,, TOTAL SQUARE FOOTAGE: ,, (slopes, ..'-,Urbane%% <br /> 1 rJ filling!. « y, ) <br /> 2ND FLOOR: /�� 0 3RD Ft°°Q{ t/A 47901i— G V/D.�t/// ❑ Review Location UMO <br /> ESTIMATED CONSTRUCTION COST: d� / 0/( and available options. <br /> (Please round to nearest dollar) -∎ ♦ --► -�► -. ♦ $ > MO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes 'lo [Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement') Wes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes A. <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) le.ve blank if none) <br /> 6. Is a location survey required? (see reverse) !, es filyelo ElDon't know <br /> 7. Is this to correct a violation? [Yes 04o <br /> 7(-) APPLICATION MUST BE SIGNED <br /> 545-112(4/OB) O (Continue on Back) -1 -p. -► <br />