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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT_to Web-App# <br /> PROPERTY OWNERi1NFORMATION„i.,? '', 'a ` w CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> M 1 IV E + c mil'L G,vst' <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 2.o 1 eAs-T I„n.,I£ 5'r. 5%.44 P ra/vie w) S 3S 9d Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60a-319 -La 67 602,-211 - 92 LI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION':: ' '- and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Rai vAar f em T C 81,,Ider'5 /Pt C ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 2961 Cbvvr}��y e_ SANvt - <br /> (City,State,Zip) U (City,State,3p) 4, ❑ Setbacks <br /> St- )rasrIf <br /> PHONE PHONE V ❑ Site Plan approval from <br /> � <br /> j o .�j�) <br /> -� , 1132- t applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS . <br /> rat Ad pwrrietiowiliblve,rt et 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION .:(http://accessdane.co.daneavims/) , ❑ Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> P rtY <br /> ❑ NUMBER P 1 . ")6 9 at frontage drawn to scale. <br /> TOWNSHIP: SECTION: ` ❑ Driveway 161216-V1 1/a: 1`+ w 1/a1/.: /L{ y permits <br /> ADDRESS: ' 9 (state,county,town) <br /> 3 02 G VGt/aJ lane S(-61 t"nl '1e I tM 5 3 SIG ❑ Sanitary permits <br /> CSM: r— LOT 12 SUBDIVISION . BLOCK/LOT (public,private) <br /> s <br /> PROPOSED PROJECT INFORMATION; <br /> PROJECT DESCRIPTION: s <br /> S I . . (2 ern►1 OS w A Trati4 /ay. 4-4941c. t 2- <br /> 1' This project is a new buil Ping or structure. Se..-"4- <br /> p� a <br /> ❑This project is an addition/alteration to an existing building or structure. V <br /> SANITARY SERVICE: �,� PERMIT PERMIT NUMBER: 2 1 °�P .- , <br /> ❑SEWER ►U SEPTIC I i 4 3S ` p��'� '7-:`-'-:,,-:_ f< : <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) -, „ x . - 3 V <br /> � 1 u <br /> 9 AREA TO NEAREST SQUARE FOOT: ,-, V, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �, <br /> BASEMENT: 1ST FLOOR: It p e e 0�� r U <br /> 7.0+1 7 62 I 4, TOTAL SQUARE FOOTAGE: ,Ir -� r -a <br /> 2ND FLOOR: 3RD FLOOR: §a�I ,e i <br /> ESTIMATED CONSTRUCTION COST: ` � . <br /> ( ) $ a--� 5l ot� ®9,7 f.P <br /> Please round to nearest dollar '�'� ♦ '♦ '�'� -+ '♦ ' '�' t -•�� x�,;a�� �� �-�^M <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 5Ko ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Lli,es OQNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? M Yes LI o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes lrl No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (lee blank if none) <br /> 6. Is a location survey required? (see reverse)tC-0.:T. 4.Al:(....D... Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? wTT ❑Yes o <br /> 31(7 J 1Z` <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) 0, (Continue on Back) -4. -4 -0. <br />