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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> r S n' <br /> I WE_ � F� �ft1 cu x ❑ Oni CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ng Stat , <br /> RA O G I t'41/Wri- K4 d Rf G U 11/ ca3 S 3S r f eed riction;CSM <br /> a " nce(# ) <br /> HOME PHONE CELL PHON E-MAIL ADDRESS <br /> 0 3-C - ';5- acice 813-g23? S e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGMAME CONTRACTOR NAME <br /> 1 N6c {4-01i9-t ll-oe 6)1.612S' Site Plan including location <br /> AGE ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Mr(N )3SSuk Ai,5 i <br /> (City,State,, Ip) (City,State,Zip) Setbacks <br /> 0 IQ 60 w Lvt E S 3cS-Zs <br /> PHONE PHONE E l tan proval from <br /> g 3 S-7/ 3 y pp le township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> •3 I4 614/1.6ag 0 U ,aoN Fl or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NU BER: CURRENT NING: ACREAGE <br /> ❑ levation of property <br /> ❑ PARCEL O S a 9 - /5I- 9/ N y oR 4‘ k( .� 4_i_ q frontage drawn ale. <br /> NUMBER 7((( r 9/ I (�r'TVC� `J <br /> TOWNSHIP: SECT I10 . <br /> Q R Ef�U A' 1�4. N E. 141/4: .51,\J <br /> ❑ Drive permits <br /> ADDRESS: ,,//��""" <br /> Janty,town) <br /> l00d �4Frvw t% OYQ GOw 'r 'W V.'tary permits U CSM: LOT SUBDIVISION BLOCC/LOT <br /> • <br /> (p blic private) i <br /> PROPOSED PROJECT INFORMATION , <br /> - AFF REVIEW <br /> . PROJECT,DjSCRIPTION: I <br /> �--6'0117 Ow ' Q t° r f Q Q r.. ® Z• ing District <br /> ❑This project is a new building or structure. ❑ Permitted Use?': <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: P RMIT N MBER: t ❑ Rural ' •• 'SS <br /> ❑SEWER SEPTIC e k�,V N'�'�,._J 1--t f r (new/•xisting) <br /> HEIGHT IN FEET / 1 NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetlan• ••--,- n/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> S'• - • (attachme <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: _I 1ST FLOOR: ❑ Erosion ` +``/0 Y [/ /1 /7U 4 TOTAL SQUARE FOOTAGE: ,, (slopes .=- I • ..- <br /> u X111 1 O l 11i r-mss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review ation Survey <br /> ESTIMATED CONSTRUCTION COST: �/ <br /> ( ) ♦ -�► ♦ ♦ -�► ♦ $' I D�// 000 .. art ailable options. <br /> Please round to nearest dollar) / 11 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Tlo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ElrYes 0 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? I 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 ti No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes kJ No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► <br /> 545-112(4/08) ) ♦ ♦ <br />