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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 4 411'A- O L GZ 'C ❑ Zoping St s; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) // Ded striction; CSM <br /> vi 5S -77 C-2ema_ Or ve. P, rc4v�14 w l 52clS�/ V ance(# ) <br /> HOME PHONE,o CELL PHONE E-MAIL ADDRESS <br /> 60 lld Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME .ANT'A CTOR NAME <br /> C�rl n i C �. �r. 10 , t l, ■ Site Plan,irtcluding location <br /> AGENT A.r RESS '_ - CONTRACTOR ADORES ' of W septic <br /> 6_ C' CvcrIceL /erra.c-(, V1CA c,SAow� <br /> (City,State,Zip) (City.State.Zip) ni Setbacks <br /> a tc es t, W / S 3 5 3 -_, l sov, w S 3')(Aj <br /> PHONE PHONE 1.)aa__--e-Vcs4 ❑ Site Plan,,apProval from <br /> ,‘O 8-S Y6 -_,, O _ /PPpciletownshiP. <br /> E-MAIL ADDRESS E-MAIL ADDRE S / <br /> 110k7 SO6 ' ' 6-4r1) .�,-.� Cc°A � lb ,�, .it 'F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (httpJ/accessdane.co.dane.wi.usn levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZO ACREAGE: P P y <br /> j PARCEL r '1 Cq frontage drawn to scale. <br /> NUMBER 09110-'3/11-gg3G- 9 C 1 I I J 0.7 .Z, <br /> TOWNSHIP: SECTION: <br /> � .')6(50 i" 3/-9-1 v '/4: S C '/4'/4:SL ❑ Drive y permits <br /> ADDRESS: c/ (st county,town) <br /> y`J 9 / 46— - ` ils-c.te <br /> Li Sanita ./mits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (.ubf ,private) <br /> PROPOSED PROJECT INFORMATION ` AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> .ning District <br /> ❑This project is a new building or structure. I► Permitted Use? <br /> A This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rura ' ..u=.. <br /> 0 SEWER J SEPTIC (..)\' (ne existing) <br /> HEIGHT IN FEET: /' NUMBER OF STORIES: (Not including basement) <br /> II I ❑ Wetland/F odplain/ <br /> Shorel d (attac ent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: Li osionCo of permit <br /> ci -t}-G-...+G '� j TOTAL SQUARE FOOTAGE: 4 lopes Isturbance, <br /> 2ND FLOOR: 3RD FLOOR: o i� �/ Illln ccess) <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ '♦ ♦ $ ISO/ MO and available options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes A No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑fres No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ©/Yes ❑ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I 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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes A No <br /> t / �—— <br /> ~ APPLICATION MUST BE SIGNED <br /> v (Continue on Back) —► <br /> 545-112(4108) bo , <br />