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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#: <br /> „z .. x .PROPERTY OWNER;:INFORMATION# .;; =::: 4'::'1. . � 4 , ,:, ,_ ,'A < t :.,- <br /> CUSTOMER TO PROVIDE <br /> OWNER <br /> L e R A d�V' 1-4 S -4a-d kliN Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> /27 3 /6/ek s4 74- /511// ,47/, 5%i5ui7,7 Ge/1 ,5-.9. 69 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> l08- J 7 7-07 72O-f '/-/ ( ri Site Plan drawn to scale <br /> AGENT INFORMATION <_; ;;; CONTRACTOR;;INFORMATION'?; : and includes dimensions <br /> AGENT NAME CONTRACTOR NAME 1 <br /> /ec Sc4/ cio ON Site Plan including location <br /> AGENT ADDRES CONTRACTOR ADDRESS ' A - of well/septic <br /> /27? //c4s4n74 h%// ,4 e/; <br /> (City,State,Zip) (City,State,Zip) _ Setbacks <br /> PHONE PHONE .�/ 5-.75-'8 I R - PI- approval from <br /> __) 6e/8-x''7 7-e)-7' 7 , ap• ,able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 11! Floor plans to scale <br /> PROPERTY/LOCATION;INFORMATION+ (http:7/accessdane.co.dane.wi.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> P rtY <br /> 0 PARCEL L, rontage drawn to scale. <br /> NUMBER 057/-/e/-80.0e-`J R/9- 2 7i-�Y. <br /> TOWNSHIP: SECTION: <br /> /0 /: /1A: 4- ,p .rive, .y.- mits <br /> 0ie/lli/: ff <br /> ADDRESS: (state nty,town) <br /> /.273 P 4-45un f ,9',// xG,. f/ouy%e" 1l// 5-7S San <br /> pe•, its <br /> CSM:_� ! } LOT SUBDIVISION BLOCK/LOT (publi • vate) <br /> Al <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: '§�T c E r-a <br /> Y714aeei ,C!/'a 't W/Ili //, 4i a-r-ea � � O a L° ' r _ <br /> ❑This project is a new building or structure. , . ' <br /> 1 14 This project is an addition/alteration to an existing building or structure. ; <br /> �SANIv <br /> `'f-z <br /> � 7 <br /> TARY SERVICE: PERMIT NUMB � �' l, '^, � ""' <br /> ❑SEWER SEPTIC ' O 4 d 74§, s r <br /> , <br /> HEIGHT IN FEET \T NUMBER OF STORIES: (Not including basement) �;a. �r. <br /> � �9q G1®wq RS �-��` <br /> AREA TO NEAREST SQUARE FOOT: * d <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r � <br /> BASEMENT: 1ST FLOOR: • ®(s <br /> i` <br /> -- 0 /c6o +, TOTAL SQUARE FOOTAGE: j s• r - , �` <br /> 2ND FLOOR: 3RD FLOOR: -k-z-tS 1 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ -► -► -i g . o b <br /> (Please round to nearest dollar) $ �✓�()dl> + a >.Y I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes aNO ❑Don'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? laYes jNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes QNo <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 IgNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 4 No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -I. -► -0 <br />