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ZONING PERMIT APPLICATION www.countyofdane.colu SUPPLEMENT#o Web�App#
<br /> TROPERTY"OWNER"INFORMATION- ,- � .:,f , 'rz;� ';.•�. .5. �_ s_`. VA c STONIER TO PROVIDE
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<br /> OWNER NAME ����
<br /> oW�ERADORESS (Number,st�ee`t,city,ta zpj 50^ Zoning Status; CUP;
<br /> Deed Restriction; CSM
<br /> 3ZC� S 'L.ay - . 5U( �c.ccv '- S3S-� Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL•DDRESS -
<br /> (LO`a `�-l3 lad G 3 Laos `�� i
<br /> ,jcv-� Q //ye.CGS V to Plan drawn to scale
<br /> AGENT(INFORMATIOII;,1• Y , .-;SrM'M9M ECONTItACTOtt`�INFOAMI/�TION ,;y'-,b{. and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> S' e Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic
<br /> (City,State,Zip) (City,State,Zip) Setbacks
<br /> PHONE PHONE n ite Plan a royal from
<br /> - p lice township.
<br /> E-MAIL ADDRESS E-MAILADDRESS -
<br /> loor plans to scale
<br /> ±: vet t= a r. � �
<br /> PROPERTY/LOCATION IIJFOR MAATLON>`_(httpa/accessdane.co,dane.v i.us/)i,�,-- Elevation of property
<br /> PARENT PARC NUMBE . r CUR ENTZ ING ACREAGE:
<br /> ❑NUMBER ' I * I i I -9" `� 0' 0 ���a) frontage drawn t ale.
<br /> TOWNSHIP: ` SECTIO
<br /> , v E 1/41/4: � ❑Driveway rmits
<br /> v ‘�a , r i e
<br /> (state, unty, town)
<br /> ADDRESS: Z 01 , Ci\l E -
<br /> LOT SUBDIVISION BLOCK/LOT n Sanitary -rmits
<br /> publi , private)
<br /> . , • ,. ; , _ - .- 'STAF REVIEWV Y
<br /> PROJECT DESCRIPTION: � ,,.
<br /> -
<br /> ,... =r yeti:•
<br /> This project is a new building or-structure. 4.M -;,,! -` X144 "'
<br /> ❑This project is an addition/alteration to an existing building or structu e. : EGA
<br /> .t.,-,4:7-47--lf-r--:,----,. .N.._-._.v.:,-_*
<br /> SANITARY SERVICE: PERMIT NUMBER: h ` _ s f
<br /> '+i-EWER . 0.EPTIC "� s-.°,� � f,.
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) E �° e
<br /> VI
<br /> ` eJaf�fFO`�,i` lit �
<br /> . . �1p. ; ,r�> eri
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) = ` .*°
<br /> D A 13 ._te 5 er{dait
<br /> BASEMENT: 1ST FLOOR:
<br /> • $ & pa p j,, TOTAL SQUARE FOOTAGE: 4, o o •
<br /> 2ND FLOOR: 3RD FLOOR: , ` k ' '
<br /> I d tee -
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<br /> •ESTIMATED CONSTRUCTION COST: �` _ � \�
<br /> (Please ) '-'∎ --► ♦ ♦ •♦ -4. i e... i -cc 24,e 6 e.. fi; .t'
<br /> Please round to nearest dollar) � x ter:-- §_° _
<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 RNo .['Don't know 3. Have you talked with the township about your project and are they in agreement? ❑Yes No. - _
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes 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) ❑Yes • lo - ❑Don't know
<br /> 7. Is this to correct a violation? - [Yes No _
<br /> . . 4( . 5 ,. ,-? 0 •
<br /> APPLICATION MUST BE SIGNED
<br /> - S (Continue on Back) —► —► —I►
<br /> 545-112.(4/08) -
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