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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION
<br /> OWNER NAME CUSTQMER TO PROVIDE
<br /> 56 ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> ,I,3.25 t/ v � 3 a Yom' AI I �� Deed Restriction;CSM
<br /> `?" Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> 7 p j S'7(- -/ C t`l7 - S-Rs 9(7 dd y Q 07r c5%FE- '7 ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> I-/Sri 4'c1 e.r- k- (arz fpm_446/1, 61)vu e:,/..4 ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 5 '• Xio -/ c/ i AA 0- k v(,i.(1 0
<br /> F
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> (1,1 j.(,r 4p7t,444 ._.e11,-- ,.G) e(__ aA...1n.O - tit tC -,
<br /> k; I L
<br /> PHONE PHONE ` ❑ Site Plan approval from
<br /> cf l(f `/o J,/O 1� i q(5/ (?(5-/ applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> /be-rct n ccrtc_cr-,q ,t;;ri less car) isordmLQ., CC rco•o;q ri,.SS.tc/rj ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: J CURRENT ZONING: ACREAGE: ❑ Elevation of property
<br /> 1:1 P RC ER Ocvt.Z 3.,-- 3 q �
<br /> 3 9/ / /4-/ 4 a_ frontage drawn to scale.
<br /> TOWNSHIP: SECTION: ,>
<br /> L� 1/'i c5-f-,C1 Y1`� 1/4: ,t-,.. IA) 141/a: ,..5/i) ❑ Driveway permits
<br /> ADDRESS:
<br /> (state,county,town)
<br /> CSM: �'�0 61-41—DIVI ON BLOCK/LOT ❑ Sanitary permits
<br /> a u (public,private)
<br /> PROPOSED PROJECT INFORMATION
<br /> - STAFF VEW' 'PROJECT DESCRIPTION: CI) q i,14 ',1C( i . if sj,a e91(01X(Arty C —�>✓J co-- s cau,)e - !,( ) rtc61 cXci Q, ) ak r, ❑Zoni �
<br /> #� r
<br /> ❑This project is a new building or structure.
<br /> ❑ Perrottte 440;
<br /> I This project is an addition/alteration to an existing building or structure.
<br /> P 1 9 9
<br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Ruiral�Addr -. ,¢
<br /> ❑SEWER ❑SEPTIC (n ;w/exislMk
<br /> >;-
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) tie ; ,5
<br /> Y ,
<br /> AREA TO NEAREST SQUARE FOOT: �� g
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) U- r '
<br /> BASEMENT: 1ST FLOOR: C .r� e e kr !
<br /> 4, TOTAL SQUARE FOOTAGE: 4, ,! 0 t a'!w
<br /> 2ND FLOOR: 3RD FLOOR: ,
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 3 j Q(;(3 i% �0v, ;g a 4F4�
<br /> (Please round to nearest dollar) _ _ . n
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ti No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? t51 Yes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? jYes ❑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) ti.Yes ❑No ❑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)
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