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ZONING PERMIT APPLICATION www.countyofdane.com uPPLEMENT�to web App;# <br /> *ROPERTY OWNER7INFORMATION_ 'F <br /> a_.:1 ; s ten_ .: r� :: = y __ r ._`_;> :<< ` CUSTOMER TO PROVIDE <br /> OWNER NAME 3 <br /> 4610 ga /VII Zonin Status CUP' <br /> OWNER ADDRESS Number,Street,C State,Zip) g ' <br /> �/ �j`� � Deed Restriction;`CSM <br /> '� q AC-a✓1 R Variance(# ) <br /> HOME PH NE CELL PHONE E-MAIL ADDRESS <br /> o 877 /o4 1 1 Site Plan drawn to scale <br /> �.:0:0-IINFORMATION:i ?, ._ti 011UOYOI4 T14011090(TIO ki—WA a'.- and includes dimensions <br /> AGENT NAME ' CONTRAATOR NAME jl��/ <br /> , flq L i.f f Ji/ets !(e(r/Aig, n Site Plan including location <br /> AGENT ADDRESS co RACT ADDRE S of well/septic <br /> F.0 ox dal p <br /> (City,State,Zip) . (City&ooA )vi Sta%e,Zip) „ _ a Setbacks <br /> 4 53f� <br /> PHONE PHONE �A n Site Plan approval from <br /> ‘ � � �jJ� applicable township. <br /> E-MAIL ADDRESS E-MAILADD ES <br /> r e w;r•. ��4a Floor plans to scale <br /> PROPERTY/L_OCATION INFORI(IIAt(ONp (http//aecessdane.co,dane vui.us/)'' w :-: Elevation of property <br /> PARENT PARCEL N MBER: . CURRENT-ZONING: ACREAGE: <br /> PARCEL /' /o �j -0 frontage drawn to scale. <br /> �� dS V �Q�� <br /> TOWNSI- - SECTION: <br /> o r.//i O �K A rtl 1'. +/A: a Driveway permits <br /> ADD ESS: �� (state, county, town) <br /> 3 173 Ou rt 41 a Sanitary permits <br /> CS(/ i�o� LOT 7 SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT=INFORMATION - gSTwRI`vjtEvVr, <br /> PROJECT DESCRIPTION: a3� : _t”. Ail: <br /> e is l'. rjc <br /> This project is a new building or_structure. • a �� f 4� _ <br /> 4�,� r: ItE�ed��7s �� �j <br /> ❑This project is an addition/alteration to an existing building or structure. r 4 k-,"-y <br /> r �9 0 : <br /> SANITARY SERVICE: PERMIT NUMBER: -���_ � � x Vic,` <br /> EWER EPTIC I� - zap 6;-.� 6=� , tv" •'" :' <br /> HEIGHT IN FEET/(5) i NUMBER OF STORIES: (Not including basement) ,_ <br /> ( ! I eeIatr'•1F bad• lnfi -1 <br /> tip akt-_ ttacP <br /> AREA TO NEAREST SQUARE FOOT 5 �: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) "�� .,t:.lir BASEMENT: 1ST FLOOR; � <br /> 3 J 6 ' 1. TOTAL SQUARE FOOTAGE: ,j, r- o°E's `�"L�L'-N, <br /> s _,g <br /> 2ND FLOOR: 3RD FLOOR: �.. �_7. �-r E <br /> ESTIMATED CONSTRUCTION COST: -WWII-&"a B t- z <br /> Please round to nearest dollar ,r7 e ab a e'e,2 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ayes ) Er. - a Don't-know <br /> 2. Is there a wetland or floodplain on or near the property? aY s it o .LDon't know - <br /> 3. Have you talked with the township about your project and are they in agreement? Vac'es • o. <br /> QHas.there been a zoning permit issued for this property in the past 5 years? Elves ONO . <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) nYes allo . Eon't know <br /> 7. Is this to correct.a violation? Elves [ to . <br /> • <br /> • <br /> • APPLICATION MUST BE SIGNED <br /> • (Continue on Back) —► —► -+ <br /> 545-112 OM) . <br />