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ZOI PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> 564 S`'Z ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number Street,City,State,Zip)
<br /> cp 3 a 5 ,)_" �� � 3 v' NV&9-/`2-c.) Deed Restriction;CSM
<br /> HOME PHONE "CELL PHONE E-MAIL ADDRESS
<br /> Variance(# )
<br /> E) S 7LJ�l c(47.3 7c S Ivy -73 Jcy 2 e s"•i cO-re1 Li Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> ,1\4',Y.1 'ham 6-f/?TL ( CLY'"tsZkid of)`,i_e -i-0 ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 0 r- .0-0)41-' k sN tJ.∎ - .•O?t 30 5 ,1.:72-e/-Rrk isa,i x)i ;-
<br /> (City,State,Zip) (City,State,Zip) , Setbacks
<br /> "h
<br /> GCO e� �i(— ra�u� 2c. 'to iL
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> //L/ yv3 3iO3 &'47 ?9 / 080/ applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS
<br /> /b2 Q_c oncvvd,u ii),e1?ress-c (yr><2.;qcr:x i-? (-0,1r , ,.4ct;, /P._S.c•,i,.7 ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.whus/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: C3 Elevation of property
<br /> ❑ NUMBER a8 / / 3--(040,s-7 G-�- frontage drawn to scale.
<br /> TOWNSHI�P4 e feuQ SECTION: t J` -1/4-1/4: 5e ❑ Driveway permits
<br /> ADDRESS v• / �4: SVV
<br /> (state,county,town)
<br /> -)es , s`e'o'D 40.„,--0___ ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION T F E>ai t#
<br /> PROJECT DESCRIPTION: l�i11n Cr.t1r 1-t$1010 *3 Part�,Hy� 1�= 11/',SJ-.Y,4lj_i.,,,P• P(-cYC(
<br /> ss 4i .Z: ,,,114:,,,-",--':,-;--1..,,- -;,.�
<br /> cxxbincf w [t,co.�-t°< - fiX, c j //-- .Zonin
<br /> <. "I C•t St' dr Y Z4�1J !re'i1HGblJ�'!' � f>tKi -
<br /> ❑This project is a new building or structure. ?
<br /> ❑ PerfT�ttt��#,
<br /> This project is an addition/alteration to an existing building or structure. a
<br /> ❑ Rura 1Addr
<br /> SANITARY SERVICE: PERMIT NUMBER: � *• `� � 4
<br /> ❑SEWER ❑SEPTIC (new/x*.tr :
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) -
<br /> Wetlan `.•;.t a �:
<br /> Sho 1 ' 14e:: Ir
<br /> AREA TO NEAREST SQUARE FOOT: , § ,
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,
<br /> BASEMENT 1ST FLOOR: ,. e;
<br /> ,l TOTAL SQUARE FOOTAGE: j
<br /> 2ND FLOOR: 3RD FLOOR: ��
<br /> ESTIMATED CONSTRUCTION COST: - s.
<br /> (Please round to nearest dollar) ". "� '♦ ♦ "� $ J'Si U00 ,
<br /> C'IC} lL� ,,� e:� '1S
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes itiNo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes allo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? aYes ❑No
<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) E4Yes ❑No ❑Don't know
<br /> 7. Is this to correct a violation? DYes I No
<br /> Z.../ APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -0 - -0
<br /> 545-112(4/08)
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