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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1.-1?Al ICtiq✓1 <br /> ❑ Zoning St s;CUP; <br /> OWNER ADDRESS ( mbar,Street,City,State,Zip) <br /> eed striction; CSM <br /> /21C r i-ri e. U i"(-( 9 c Q7 • nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 7 5 l J 76 go Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME / /I CONTRACTOR NAME <br /> 5 C o L/ `I.yi li.4J sd- R- 2 u*(o 1` Si Plan including location <br /> AGENT ADDRESS SS CONTRACTOR ADDRESS <br /> 5.. . km 3!Zci (1` 2v✓ rz�, o well/septic <br /> (City,State,Zip) (City,State,Zip etbacks <br /> PHONE PHONE ❑ Site Plan royal from <br /> 6 0 6 - 121 gO(/ I applic a township. <br /> E-MAILADDRESS E-MAILADDRE Ail <br /> CO iLf 51rr(1711c [,',/t, ,Co Ali ❑ loor ns to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT Z NI ACREAGE P p y <br /> ❑ PARCEL O 2 /a^ /'??.-9400 - 5 Ll 'N y/ i 9 O frontage drawn t scale. <br /> NUMBER / / �J� j� (� <br /> TOWNSHIP: SECT,0117 S ❑ Drive <br /> ac cr 1 C(, c-‘), 1/a: S 1 1/4:■ D e,county,permits <br /> town) <br /> ADDRESS: /� n \ l� f I <br /> ,`(^J \ \ U 1 I G <br /> ❑ Sarnta ermits <br /> CSM: ^ LOT ( SUBDIVISION BLO K/LOT <br /> 14^S (j (pub' ,private) <br /> PROPOSED PROJECT INFORMATION S AFF REVIEW <br /> PROJECT DESCRIPTION: / ' <br /> c�r Y / a Zo ing District <br /> ❑This project is a new building or structure. ermined Use? <br /> WI-his project is an addition/a ration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMQF.13• ❑ Rural ' "• -ss <br /> II <br /> ❑SEWER PTIC 1n •existing) <br /> HEIGHT IN FEET / NUMBER OF STOR S: (Not including basement) <br /> ❑ Wetjan 0- ••dplain/ <br /> S"• - and'°(attach A-nt) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ trim= • ° • perm' <br /> �� 4, TOTAL SQUARE FOOTAGE: 4, mss, ■iStur , <br /> 2ND FLOOR: 3RD FLOOR: <br /> / c ' jl iiii • access) <br /> Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: <br /> ♦ ,.♦ ♦ -..0. ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? �❑Yes No won t know <br /> 3. Have you talked with the township about your project and are they in agreement? ,l es <br /> ' es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Cr Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank' none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> r----- APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► -♦ <br />