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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 /> 11.)rs IAeak►c."a N� ❑% g ;CUP;OWNER ADDRESS (Number,Street,City,State,Zip) _ d triction; CSM <br /> 74121.0 ..1..771•4' 11 e.t-• f .ice.:-ice nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 1— . S e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1 tliv+ZN�t .�zfe+41-N)1;-r. .6faNter t . t. Mrtkr Jwell/septic e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS A <br /> -71 7c C i4.,.'.411 . .- c.-4.. 71-- r:sires 11,LL- 4l,- <br /> (City,State,Zip) (City,State,Zip) <br /> Setbacks <br /> 1001►yv1.yl✓ Lilt" `. 5_f j,a1-Lr i 1K4 LL' 1 6--- ;ti—1 <br /> PHONE PHONE 1 ❑ Site approval from <br /> Lst+- - - Jr ai LoC. - 5 I —/ry Sri ap. ' able township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> _ . Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) (p� <br /> PARENT PARCELN BER: CU RENT ZONING: ACREAGE: Y Elevation of property I❑ NUMBER O `'"' I 1Q , frontage dra to scale. <br /> TOWNSHIP: O SECTIO : r 1 1 <br /> N ej <br /> I� 1/4: N E .4Y4:ShJ ❑ Dri ay permits I <br /> ADDRESS: ` ate,county,town) ■ <br /> I r_` d‘l ,� <br /> �l co •� le Q \ C I Q ❑ Sanitary permits � t <br /> CSM: LOT :DIVISION BLOCK/L• V <br /> li ■ <br /> 1 , S (• blic,private) CG <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ge4C2tcvie-Er jtal •C.tr:in r4- 1VrrCaik.d ! ZO iing District <br /> ❑This project is a new building or structure. ❑ rmitted Use? <br /> Ig.This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ` _ ❑ Rural ``°r -s <br /> ❑SEWER .EPTIC W,V G0.(( (n°' existin' <br /> 1 <br /> HEIGHT ICI FEET I NUMBER OF STORIES: (Not including basement) <br /> Ol(© _J__ ❑ Wetla•of •odplain/ <br /> Sh•reland ( chment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached arages and above grade decks or porches) <br /> ❑ rQSItM trot permit <br /> BASEMENT 1ST FLOOR: 1 1 TOTAL SQUARE FOOTAGE: ope ,disturbance, <br /> Q <br /> 4 ♦ Ilin access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> q 0 9f Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -i ♦ ♦ ♦ �/�Q� _ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑ es • ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es - • <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes M No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank i none) <br /> 6. Is a location survey required? (see reverse) UYes 21 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue On Back) <br />