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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to.Web-App# <br /> PROPERTY.OWNER INFORMATION a.,; , .;_,:' Y; W4,=#,,; .="x.'.=,-,1:"-:-`.;:;"),"- -.11-1';'. <br /> x..: + -?-:- w;' CUSTOMER TO PROVIDE <br /> OWNER NA E .r <br /> lj h '--x •A 4 , lie / is /`I e / A.- /`��j t ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,St(ee(,City,State,Zip) / g ' ' <br /> Deed Restriction;CSM <br /> CP C' c)%-t..4 ►vy /71 c I75.1•1 R I_ Variance(# ) <br /> HOME HONE CELL PHONE( E-MAIL ADDRESS <br /> 3S----?O.S • a k / / <br /> e W%sc. eI K ❑ Site Plan drawn to scale <br /> AGENT INFORMATION ;:; CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT•- NAME nn <br /> ��c A Mo-r icc.. £ ar. . ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTO=.'DR S9' of well/septic <br /> ce)6 Limiter,1 Pr- <br /> (city,State,Zip) (city,sate,zip) n -535-9 6 ❑ Setbacks <br /> L., v i-'i- . rry j trAiire, <br /> PHONE PHON13 ❑ Site Plan approval from <br /> &9 —1 YS —l 6 p applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION;INFORMATION::(http:l/accessdane.codane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT NING: ACREAGE: P P y <br /> ❑ <br /> NUMBER O 5-0 ?,O,��r./QSUS� H — 3 ► frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> , , ❑ Driveway permits <br /> ci� °'� ° � �' ��`' �' (state,county,town) <br /> ADDRESS: <br /> / / �{ <br /> 7 f°C2 C)c�u,•t y rite-etk011 /2L+ fl-�t ookQ�y'n S3s-2 ( ❑ Sanitary permits <br /> CSM: LOT / SUBDIVISION f BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION; � -� <br /> PROJECT DESCRIPTION: �; <br /> .�fhis project is a new building or structur-`. _� Hp E(L '' <br /> � �4 9���5���t ot Vi, . <br /> ❑This project is an addition/alteration to an existing building or structure. r- : ., = <br /> SANITARY SERVICE: PERMIT NUMBER: _ , : °-, <br /> ❑SEWER SEPTIC a,4 " ` <br /> HEIGHT IN FEET NUMBER OF STORIES: of including basement) ,; r �., , <br /> AREA TO NEAREST SQUARE FOOT: F-' � � , k,..47 1 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �' 8._ -fig g ® �. <br /> J 4, TOTAL SQUARE FOOTAGE: ,�, -`: i f + <br /> 2ND FLOOR: 3RD FLOW: 4 ;' <br /> 3 - d 132 . = k <br /> ESTIMATED CONSTRUCTION COST: f <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes . No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 210 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ..- ❑Yes o r 20O°1-PO $ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes J34 No <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 ,IErNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes *No <br /> '370 ) 'D`1)-7 -- °C‘' ,4 <br /> i 1/}C1 0 V APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -■- <br /> 545-112(4/0B) 1 ' <br />