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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> ,, 12e165SLerg- <br /> LI Zo in <br /> OW R ADDRESS (Number,Street,City,State,Zip) g St S;CUP; <br /> I�ZS 600 f.ISSN r2�71 C 1t•sS�/s1 St, PJi. 53 Sz.S? D ed striction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS + ar' ce(# ) <br /> 7 9 8—LZ '4 516 3 So ' .roess[Qre toes S 410L5O�s s Co,V Si a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Rows, .-#S.Atf 4p,,,4*; S' e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> `V _ I if 2.,c 1Sekt,4"oag <br /> (City,State,Zip) (City,/fState,Zip) �Q/ Setbacks <br /> PHONE C. Ito ss /CND HIV St NtZ Sri SZK <br /> PHONE ❑ S. Pla pproval from <br /> (069-718—Z7-9.1 pl' le township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) <br /> PARENT /P'�AR ELNU BER: CURRENT ONING: ACREAGE Elevation of property <br /> ❑ PARCEL `J © /�,� o ,O �a a(R) L. f outage drawn to scale. <br /> NUMBER ((( y <br /> TOWNSHIP: <br /> 2 SE ,O^} •.71E(-Ik-y 14:'...S 1/a 1/a: 1� Driveway permits <br /> ADDRESS: 9°°Z/ > (state,county,town) V <br /> CSM: LOT SUBDIVISION BLOCK/LOT ' ❑ Sanita ermits <br /> q 2 rj' (p lc,private) <br /> PROPOSED PROJECT INFORMATION Aft REVIEW <br /> PROJECT DESCRIPTION: , Q <br /> J\ i ,Wing District <br /> This project is a new building or structure. !i Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ ,f . Address <br /> . _ - existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 3gie <br /> iv t !a j ❑ wetlan` •dplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorel d (attacftment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ EmsionControl permit <br /> as/ Cf 4, TOTAL SQUARE FOOTAGE: 4, (slopes,d�ur��, <br /> 2ND FLOOR: 3RD FLOOR:`P filling/access) <br /> 8Gy <br /> ESTIMATED CONSTRUCTION COST: Q I ❑ Review Location <br /> (Please round to nearest dollar) ', "♦ '♦ -♦ ♦ ♦ $ e CIO O <br /> / and available options. <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? ❑Yes lei No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 14Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes tallo <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 J Jo LI Don't know <br /> 7. Is this to correct a violation? C3 Yes cii,No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -♦ -i <br />