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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> f i
<br /> PROPERTY OWNER INFORMATION
<br /> OWNER NAME CUSTQMER TO PROVIDE
<br /> C eiQID`C J ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> 8%/l 0 4 M -f'la,,t v z_, /1-1,u-ems e---
<br /> Variance(# )
<br /> HOME PHONE CELL PHONE E-MAILADDRESS
<br /> 173 3 q q ac)co 173 34 4 /Flo ccrt/. 0,." fcr SCCilu(Cd. Carr' ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> �,50( r1 6 tr-o - Can c o-LOCk=eA. 00 t-L.,¢.Q.ei ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> S- C. , -y-tezi. S, @ 0 3& sd s s.d-9- aS ALCn-6 G
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> 1-1 L-1a1�1X/> i L.t_o fJ 0 U S � �� 1 g-- (o 0 D 0 S
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> `-1 I`1 '10 3 310 3 &`l-7 q pj I d 6 0 3 applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS
<br /> 1be- Xoncardl'ovoi ft(tSS (0,7 j 44 �eada}-Q,cohcordic)tA)Iv Jess ow, ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) CI Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y
<br /> 3 PARCEL 0 7/0 3La / 9'Oo0 , ✓I-1 4 A� frontage drawn to scale.
<br /> NUMBER _
<br /> TOWNSHIP: j SECTION: ❑ Driveway permits
<br /> 6 �r �u/�J4_, 1%: SF� 141%: cst/V y p
<br /> (state,county,town)
<br /> ADDRESS:
<br /> ` -q3 /.
<br /> `3a 3 ,sa'''U ' ❑ Sanitary permits
<br /> CSM: LOT i A- SUBDIVISION BLOCIVLpT (public,private)
<br /> ol "Ovc.v�x �
<br /> PROPOSED PROJECT INFORMATION
<br /> PROJECT DESCRIPTION: oICCD1-J,/�) cx o-rw , t-ps- p (�vll�C�. a L �' , t, '
<br /> 11 auaQ Q, bt t l2-, Zonlit I �,�
<br /> ❑This project is a new building or structure. _
<br /> This project is an addition/alteration to an existing building or structure. t 7 4
<br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural ' g"
<br /> (nf w/ex .
<br /> ❑SEWER ❑SEPTIC ,� r
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) ' etj+y{'I 1.
<br /> 14„,„,,,,1:-:£ ,U �a' e ` -`
<br /> AREA TO NEAREST SQUARE FOOT: 3
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches)
<br /> BASEMENT 1ST FLOOR: i-y ,at st e
<br /> 4, TOTAL SQUARE FOOTAGE: 4, # .�-t$a/$ : ,?
<br /> "� °E L� �yr � ; �"-
<br /> 2ND FLOOR: 3RD FLOOR: rc IR
<br /> ESTIMATED CONSTRUCTION COST: � er � :
<br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ "♦ ♦ `� 7(ooc) ,, ""7.1.t.�
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Flo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes J No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? C,t'es ❑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) CaYes ❑No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes ,10
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<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back)
<br /> 545-112(4108)
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