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. t‘6 lextse4- • 075 57,0-. j17-4) <br /> --P-e..,e. P <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> NAME /� <br /> � f/ . te1/ v� Y ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Num er,Street,�ty, ip) Deed Restriction; CSM <br /> 6/9-y Mt, rug///,2o1 . 1 52 /O1A16, oil s35z s Variance(#HOME PH NE CELL PHONE E-MAIL ADD SS <br /> OF/7495.— _,I._ 7 6dFr=2-- -S 2��4 /pre - mid S,/Ja- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions ' <br /> AGENT NAME CONTRACTOR NAME <br /> c5-0L- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE 'Om <br /> applicable township.-E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ❑ Elevation of property <br /> ❑ <br /> PARCEL //d 1�/.g f _F. �_/C frontage drawn to scale. <br /> NUMBER <br /> TO HIP: SECTION: <br /> t/4: 14 t/4: way permits <br /> of��' (state,co , wn) <br /> ADDRESS: p / /2555,141,i , <br /> CSM w��i/ rte"� � _ Su <br /> ry BLOCK/LOT Sanitary permits <br /> (Pu , • <br /> PROPOSED PROJECT INFORMATION <br /> TAFF REVIEW <br /> PRQ,I,OT DESCRIPTION: <br /> pa-t r Oni District <br /> ❑This project is a new building or structure. ermitted Use? <br /> a-This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: I,ii{.ii� "--. <br /> Li <br /> -�' (new/existing) <br /> SEWER .SEPTIC � <br /> EIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ) ❑ Wettand/Floodplein/ <br /> AREA TO NEAREST SQUARE FOOT: 5horeland`{at# t#ment} <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ E 14'"C"l #itrf-.( e/II!'t <br /> BASEMENT <br /> itT FLOOR: 4, TOTAL SQUARE FOOTAGE: 4, (slopes,distu f ; <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ,'4 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q� and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ '♦ <br /> u , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EN ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes <br /> 21 No CI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? l -Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes El 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 Ilit,No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes GIN o <br /> bcie APPLICATION MUST BE SIGNED <br /> :2.4%° -I- (Continue on Back) ■ —► <br /> 545-112(4/08) <br /> s 4, L czressev-.ro--1 2_24 - 31 3‘ <br />