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X ( 3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME/ . i V '-// /°9 <br /> -.)C rvi e--S V.1'4 r CA On "C € jtrnej 3hindn Zoning Stan's;CUP; l/ <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> pia 13o>' 6 7 i /a.r5 /i /Jf 535'59 Variance(# ) <br /> HOME PHONE '/ CELL PHONE E-MAIL ADDRESS <br /> D1 a 9-87"0 3 JO/11 e., A foe-. ( '/ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of wel septic <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE 1l�Plan approval from <br /> r appf able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus!) <br /> PARENT PARCEL NUMBER: »�,��,.J RRENTZ NING: ACREAGE: levation of property <br /> D PARCEL ]� p _ ,/ J e j- ' fro, age drawn to scale. <br /> NUMBER V��Q/�IO�2 �Y�- UU� <br /> TOWNSHIP: SECTI N: -1 <br /> M SE yN j Ya: /a'/a: to Driveway permits 7 <br /> ADORES : ` � (state,county,town <br /> y7 o® �G� �U ? / / �/�/ / � 4�53 5 1! Sanitary permits <br /> CSM: LOT UBDIVISION BL�OCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION:Cjit)giei irk /9, 1,5/��Ce_. Itl District <br /> IN This project is a nevAuilding or structure. Pitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. , <br /> SANITARY SERVICE: PERMIT NUMBER: f f� — Address <br /> ❑SEWER NSEPTIC 5 C� y/ fl O'xisting)HEIGHT IN FEET: �� NUMBER OF STORIF : (Not including basement) <br /> a' etllttf3d1ITt/ <br /> AREA TO NEAREST SQUARE FOOT: Shorelarid �attAGltlTlerit) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) it <br /> BASEMEN 1ST FL R: Li Erosioneontroi" <br /> CO 0 Z I/ 4, TOTAL SQUARE FOOTAGE: 4,, (S s,dis u��, <br /> 2ND FLOOR: V 3RD OR: �� 94- filling/access) <br /> 3 �' ►�' Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ SU U . .a available options. <br /> (Please round to nearest dollar) / U <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Cl Yes tgi No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 111(No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? OYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 4 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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes f'No <br /> APPLICATION MUS BE SIGNED <br /> 545-112(4/08) (Continue on Back)T <br />