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ZONING PERMIT APPLICATION www.countyofdane.com ;SUPPLEMENT to Web-App#. <br /> i ?45 ' ',��-ill :M -�•-.` �., ' ` ` CUSTOMER TO PROVIDE <br /> PROPERTY OWNER:-.INFORMATION a..,� ..,y , ,, , <br /> OWNER NAME l, ,1 <br /> 04A)`TM//" ` ` 3. 21- A g/A6- `i f ( Zning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip_____ , `I 7 1 Deed Restriction;CSM <br /> 773 D,Ak Gl2 (RL / Ap/S )) �2-J 23 Z)7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS ,,� <br /> 4 0 i 62-` -O� l_7 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR:INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ,�,e <br /> g Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS ��of well/septic <br /> (City,State,Zip) (City,State,Zip) [ Setbacks <br /> PHONE PHONE • / Plan approval from <br /> '� applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS ,� jj <br /> LW Floor plans to scale <br /> PROPERTY/LOCATION:INFORMATION'.:(http://accessdane:co.dane.wLusn Elevation of <br /> PARENT PARCEL NUMBER: _ CURRENT ZONING: ACREAGE: property <br /> P rtY <br /> P NUMBER PS:97=2 S )9S X50 A -a- / , . 7 frontage drawn to scale. <br /> TOWNSHIP: SECTION: , / - <br /> 3�_// y Q?Lc IA: .5 t- %I : A L- veway permits <br /> ADDRESS: <br /> (state,county,town) <br /> . - 9 5 � �' /6z.P 4[ 7 . nitary permits <br /> CSM: LOT 610 SUBDIVISION BLOCK/LOT private) <br /> te 1 <br /> PROPOSED PROJECT INFORMATION;! VS <br /> PROJECT DESCRIPTION: ' ' ��* A �9 r1k <br /> This project is a new building or structure. m <br /> ❑This project is an addition/alteration to an existing building or structure. r : <br /> SANITARY SERVICE: _ 'ef a( ` '".' <br /> PERMIT NUMBER: ���„ [��,, ter, ,� <br /> ❑SEWER LM SEPTIC - �� 6 Q ; °� � " 4- <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 33iip�3k <br /> ®Ft� �r' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) i, <br /> BASEMENT: 1ST FLOOR: e e..�q a s <br /> 3 fi,� mot , <br /> b oZ 3 5 j TOTAL SQUARE FOOTAGE j ..f: ,- �,, !. <br /> l e .1: , . <br /> 2ND FLOOR: ��\\ 3RD FLOOR: - - g� <br /> ESTIMATED CONSTRUCTION COST: T / g ® q s,p ,a, <br /> (Please round to nearest dollar) /� ('�Q �� 4 x -e:/:=11.'"'T ‹- h r, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes Lb No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LS'es ❑No ❑Don't know 7576E <br /> 3. Have you talked with the township about your project and are they in agreement'? Q'S'es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ❑No 2.op(-t—/ y f <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 1 <0 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes C 4o <br /> ALIATIUSED <br /> (CoPPntinue C on ON BacMk)T BE-►SIGNED <br /> —► <br /> 545-112(4/08) <br />