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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIT ,,/y <br /> OWNER NAME L( <br /> ame_S a.Y1A t I1 SC(. RCt.r�, �J osePv` Rck,pe-) ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> S <br /> LI H Z C' L 16� I R Deed Restriction;CS OAD Iriance HOME PHONE CELL PHONE E-MAIL ADDRESS lng 5U 4LfI e Plan drawn to scale /73> <br /> AGENT INFORMATION CONTRACTOR INFORMATION and inclu irltn des d ions <br /> AGENT NAME CONTRACTOR NAME ( �r <br /> luding location• <br /> AGENT ADDRESS CONTRACTOR ADDRESS ep ti.c <br /> ((City,State,Zip) (City,State,Zip) 63/3tY1-5M/4-0 <br /> Setbacks <br /> PHONE PHONE Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> NQ Floor plarr)o scale / <br /> PROPERTY/LOCATION INFORMATION (http://accessdane,co.dane.wLus/) <br /> A PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation Of roperty <br /> PARCEL frontage drawn to scale. <br /> NUMBER 0 o?: I o i to-323-S50-CZ , - a(`I 1 S • 142_ <br /> TOWNSHIP: SEC O" A1'/'4 <br /> Gwv� a t 1 2 1/a: 141/x: VI/ Driveway permi <br /> Q acvr,n C.�ru.i� <br /> ADDRESS: �J (state,coun •) <br /> i Sanitary -:.'ts N/4_ <br /> CSM: or . LOT LOT ( SUBDIVISION BLOCK/LOT (public pnvat: <br /> • <br /> PROPOSED PROJECT INFORMATION STAFF REVUE <br /> PROJECT DESCRIPTION: �- <br /> L�2c.k. 3C. x 2 3 5 rx y Q Zoning District ' — 7 <br /> ❑This project is a new building or structure. "e Permitted Use?6 I` <br /> This project is an addition/alteration to an existing building or structure. F <br /> SANITARY SERVICE: PERMIT NUMBER: Rural Ad• se <br /> ❑SEWER U SEPTIC ne m" , t <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / W Ioodpiain/ <br /> / �'SShareland ttacttrnent) <br /> AREA TO NEAREST SQUARE FOOT: -_ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) �. <br /> BASEMENT: 1ST. Q(� (.1 rC�SIOn ' ttttrC / / <br /> �(I . . 1 a- <br /> (/ TOTAL SQUARE FOOTAGE: , , t <br /> filling/access) 7 /I <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2i- t e6 -----04 Review Location Survey l <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ,.+ --► ♦ a r) and available options. <br /> (Please round to nearest dollar) $ o , G� U <br /> 1. The property is within 300 feet of a strea , •r 1000 feet •m a pond or lake? ti? Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near t" - • •.erty? 'es 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes '1 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? , ❑No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal C / (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes c No Li Don't know <br /> 7. Is this to correct a violation? ❑Yes 2No <br /> APPLICATION MUST) BE SIGNED <br /> (Continue on Back <br /> 545-112(4/08) <br />