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1 -(s')K -D* 7S ^ 1 � _ 6 SX1'1 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> p ID OWN NAME t1,'I-e i '.\ - V <br /> / Zoning Status;CUP; <br /> OW ADDR SS (Number,Street,City,State,Zip) ed Restriction; CSM <br /> Van ce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> NI ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION -nd includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> (f <br /> J W l 't me Y-- t /septic Plan including location <br /> AGENT ADDRESS CONTRACTOR .:.RESS <br /> 5 zq I Ylaaese\I C+ 44-- $9 <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> t: ..ii. a - • 'w t 3 <br /> PHONE PHONE MI -Ite Ian approval from <br /> b0S- $ I - 0031 .pplicable township. <br /> E-MAIL ADDRESS 1 E-MAILADDRESS <br /> go�tr-o..h n' rye &�ac.ne} -E oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acc:essdane.co.dane.wi.us/) <br /> t7 P ro e <br /> e ation of <br /> PARENT PARCEL NUMBER: CUR ZONIN ACREA property <br /> ❑ PARCEL / �\ Q'0 0 P� •ntage drawn to scale. <br /> NUMBER "�"" 3�� d�L 0 <br /> TOWNSH SECTION' <br /> �}-- .. .e/f i ❑ Drivewa.,• = mits <br /> I 1/a: 1/a 1/a: <br /> ADDRESS: 14 4 I C)� (St. ,CO ty,town) <br /> 5 C3� .Ls� ❑ Sanit. • is- mits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pu•lie,p 'vate) <br /> PROPOSED PROJECT INFORMATION STAFF `EVIEW <br /> PROJECT DESCRIPTION: <br /> � <br /> e C. (Ls A . ning District <br /> ❑This project is a new building or structure. _ermitted Use? <br /> _ s project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBE,)=t: urai l�C tress <br /> ❑SEWER PTIC ��// <br /> HEIGHT IN FEET NUMBER OF ST RIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FO T: ° ° ' attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: / <br /> =row•e ' s s , . it <br /> j TOTAL SQUARE FOOTAGE: 4, (s •s_-, 'isturba e, <br /> 2ND FLOOR: 3RD FLOOR:R: full , a <br /> - ) <br /> 's e' :w Luca ,+• urvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ^ and a -liable optic - <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 zlo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? SYes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes ❑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 . 111.tio ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes -�No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —* -♦ <br /> 545-112(4/08) <br />