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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 /> '/IMAA (AC " IE- ❑ Zoning us;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Striction; CSM <br /> Ion OF&• ypriot,I i-1-tc- i/bAb, 73, o WI .-.S 0g a lnce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> fir` /5 g SJ' e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME y� CONTRAO,OR NAME ; <br /> ff) /uAcacc- kE i S' a Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> /oil Oassa, /ham i c3At) <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> g . 3„� OS: 53.50 ' <br /> � ' <br /> PHONE PHONE 7lappovaifrom• <br /> !+?-1+. I S£SI able towrLStriE-MAILADDRESS E-MAILADDRESS ..tacale <br /> PROPERTY/LOCATION INFORMATION (http://accossdane.co.dane.rnrl.us/) ion of property <br /> PARENT PAR UL BER:Jf�n �yURRENT O • e: / ACREAGE: P P Y PARCEL S❑ NUMBER n l V Q ^ 'r7'0 1! ,� 3 frontage drawn to ScAle. <br /> TOWNSHIP: 7QV SEC I 5_ 1 <br /> M lJ 'A: N 1/a'/a: '�V J ❑ Drivew ermit5 <br /> °'S: st county, own <br /> ADDRESS: ( � ) <br /> /0/7 C g....6 ,iftr vt' Mu.420 tec.i..EU/i l•Jy s3Sog _ Li Sanitary p- its <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (put IC • 'vate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: `/ <br /> &ORM 6 1( j Zon' District <br /> a"This project is a new building or structure. rmitted Use? <br /> ❑This project is an additio alteration to an existing building or structure. r— <br /> SANITARY SERVICE: PERMIT NUMBER: RUr <br /> D SEWER SEPTIC (ne /exist g) <br /> HEIGHT IN FEET: NUMBER or STORIES: (Not including basement) <br /> ❑ etlan dplaiI K FscZ (A ee . l <br /> Sh and (attachment <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> ❑ Erosit nCon,•• •-rmit <br /> BASEMENT 1ST FLOOR: I TOTAL SQUARE FOOTAGE: ,, (slopes twos, <br /> °�4 Oa filltn• -cress) <br /> 2ND FLOOR: 3RD FLOOR: <br /> o21+00 ❑ Review L urvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ , and aV a options. <br /> (Please round to nearest dollar) .Z../ 600 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 2INo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the propetty? ErYes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes El No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? aYes ❑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 EtNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> 3 C) MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue APPLICATION on Back) -► <br />