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06/16/2009 11:03 608-267-1540 DANE CO PLANNING PAGE 06/07
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<br /> ZONING PERMIT APPLICATION ww.countyofdane.com SUPPLEMENT to Web-App #
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<br /> PROPERTY OWNER INFORMATION CUSTOMER TO'PROVIDE
<br /> OWNER NAME
<br /> ' ,u,d /4( a e P• �C rnt-ti j/71 4) oiling Status;CUP;
<br /> OWNER ADDRESS 1Number,StreoI,My,State,Zip) Deed Restriction;CSM
<br /> 145(o Gnccnw- Ad /narshed WE 5355 Variance(# )
<br /> HOME PHONE CELL PHON�- E•MAIL ADDRESS
<br /> l o:- tiFb 3447
<br /> ;,'. -o7 dh eCilk ' - fie» ' : *AZ lerr. c. ite Plan drawn to scale
<br /> AGENT INFORMATION I CONTRACTOR INFORMATION and• dudes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> —0 f fi C,r%S ite Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 6125 Et , p
<br /> (Oily.State,Zip) (City,Stare,Zip) -tbaoks
<br /> _ Skun Pia4,1`n c. WT 535q0 �1
<br /> PHONE PHONE `_ t; Plan approval from
<br /> root-8a5-1c) O Loa- `tV`t-3161 a icable township.
<br /> E-MAIL ADDRESS E-MAILADDRESS
<br /> dfCon Cfl0fl ..0 c•Altne• Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.w).us?)
<br /> PARENT PARCEL NUMBER: CURRENT ZONIN : ACREAGE: tevation of property
<br /> 0 MBEFt 0'16/9 - -07 -8315- R- R .S frontage drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> 1/a: �Sw �i&'/a: N E away permits
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<br /> P151, G_ e.
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<br /> t t 53555 Sanitary permits
<br /> CSM: UT SUBDN1SION BLOCK/LOT
<br /> `l 8 8 / (public,private)
<br /> PROPOSED PROJECT INFORMATION -- - •'- '`" '
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<br /> PROJECT DESCRIPTION: , ' x., Y,"!',:$?. .i+,�I .fizt n �ir�
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<br /> 3 This project Is a new building or structure.
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<br /> NI This project is an addition/alteration to an existing building or structure. "'j •"i}``�"'•jii;O't' L�S` ' r`I''r." �_`:; t� ,,,,;'
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<br /> SANITARY SERVICE PERMIT NUMBER: ‘.."ii-.,;,:.:.:: , t°r
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<br /> ❑SEWER SEPTIC `'ti`;". ,„.:. ".,:.n ',f, °i°'I 1.,4'11 i
<br /> HEIGHT IN FEET; NUMBER OF STORIES: (Not Including basement) bYYdbs."s^;, a d; '2':',410;
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<br /> Geivr..es, g , ri-7_04-1 c l0, Botff) - I _ to - _ ,
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<br /> AREA TO NEAREST SQUARE FOOT ∎ :"�"�`Fc".;1:74-7:,9,,,:,'"i'f'` ie" u:•,itt I,a;1
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<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 0't,' " f {I
<br /> ISAUE Wir! 1ST FLOOR: 144o c Y t7':-... ' n
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<br /> � 1�f11�.1�{.y V'F� ,I,
<br /> Jr` I. +, TOTAL SQUARE FOOTAGE: ,` P l 'rr ;
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<br /> rj 2ND F •OR: 3RD FLOOR: Y•••;1;j N.ii.S'I .q+' •J .4' " '
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<br /> ESTIMATED CONSTRUCTION COST. � _'• ^pkC1i 1 1t t 1 7 1;i, ••(Please round to nearest dollar) 5 • z,: '"' a1''. '+.:,";'"'t:" Ye.''::,;. -.� .
<br /> 1. The property Is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes Cat No C1Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 123 No Cl Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? tgi Yes ❑No
<br /> 4. Has there been a zoning pennit issued for this property in the past 5 years? El Yes Si 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) CI Yes 0 N 3 Don't know
<br /> 7. Is this to correct a violation? ❑Yes El No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -4 -. -4.
<br /> 54 5.112(4/08)
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