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. - --/ S C t4) <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#- <br /> PROPERTY OWNER INFORMATION„ ,-,, z_ i..1., �,' ti. „ a., < 6 .{ CUSTOMER TO PROVIDE <br /> OWNER NA E <br /> 1 t4 A- &T -r-- A- ` OW Zoning Status;CUP; <br /> OWNERADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> \,/ <br /> 3 5-0/.4 ( I 6� -0`�''-� Variance # <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS ( ) <br /> a 3 2 l 2 O P4 Site Plan drawn to scale fr <br /> AGENT INFORMATION - CONTRACTOR INFORMATION` ' xis a d includes dimensions <br /> c <br /> AGENT NAME CONTRACTOR NAME <br /> \Tc.1 Le. t_L--C_ 7i Site Plan including locatio t-72 <br /> AGENT ADDRESS CONTRACTOR ADDRESS if well/septic <br /> e <br /> Zip) �a_V`J�` 4 3/ � ‘ti■f \c I3' Setbacks <br /> (City,State,z \ (City,State,Zip) •� <br /> PHONE _ / PHONE M Sit I pproval from <br /> ��j — 3 (�, . g�p p ap ' ble township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> t2 k C��,. o 'Floor plans to scale <br /> -fit-. u <br /> PROPERTY/LOCATION INFORMATION ':(http:1/accessdane.co:dane:Ni.us1) <br /> PARENT PARCEL NUMBER: CURRENTZON G: ACRa GE: C evS property <br /> 0 PARCEL p 7® g 30 3 9S6o? _ -_-.. A - 11 /s- front raven to scale. <br /> NUMBER � <br /> TOWNSHIP: SECTION: <br /> ' aC.T A-4-0 30 1/: S\(\j /%: r J • rl a ermits <br /> ADDRESS: (st ,c linty,town) <br /> SA '( l t`'_ `-__ AAc.' ► Sanif: •-rmits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub' , •rivate) <br /> PROPOSED PROJECT INFORMATION. '” i TAB <br /> -r <br /> PROJECT DES RIPTION: < "s+ - <br /> IS Lc_k Gr t L O T-G `n1 9 gfil°-Ash ' , , <br /> ❑This project is a new building or structure. ` <br /> je I,.. .d � � r 1', tt' <br /> AThis project is an addition/alteration to an existing building or structure. � n : . <br /> SANITARY SERVICE: PERMIT NUM:-:: - �' -- J. <br /> ❑SEWER �CSEPTIC i! . � 4:i c ; <br /> -- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not in luding basement) _:s ' " <br /> al :-:;"::::::::''`;'S,12 A r . :•l. .a ,;:1 i :. <br /> : <br /> . s 5�_ r- <br /> ��t� <br /> AREA TO NEAREST SQUARE FOOT: � �� s � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) t , .' .' <br /> BASEMENT: 1ST FLOOR: wax ®I* i� e ®� <br /> `$X /) 4, TOTAL SQUARE FOOTAGE: ' 5= „-.. 1, ' <br /> 2ND FLOOR: 3RD FLOOR: °. ` - ���- 3 '''i 0 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ f p ' n r 2`1::;., \ <br /> (Please round to nearest dollar) �Q CO <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Colo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 12Kio ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? L'Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 2rNo <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 'No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -t► <br /> 545-112(4/08) <br />