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• <br /> .ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO . -OVIDE <br /> OWNER NAME 1/ <br /> f c ' c•44 e f" CI Zoning .tus;CUP; <br /> OWNER A RE (Number,Street,Ciry fate,Zip) 1 <br /> btu, Dee. ,estriction; CSM <br /> 7 S 5 0,0)6. r w 5 I •;v•e-, f °C r<"i--/ G, V riance(# ) <br /> HOME PHONE _ CELL PHONE E-MAIL ADDRESS <br /> ' 1 -13-/4"/5 Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION a d includes dimensions <br /> AGENT NAME f� CONNTT ACTOR ME / <br /> O' i��d r",tLta:c,.ti,s-e-c ,I '` Y�`leat4 5' r Jac ,1 A6 Site Ian including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS /, Of ell/septic <br /> (City,State,Zip) (City,SR,Zip) .., 2 _ etbackS <br /> ' . p /cif <'� 'a -;� <br /> PHONE PHONE sU Site PI pproval from <br /> (,70 15 — 76 V - 2 s- app• able township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://acressdane.co.dane.wLus/) evation of PARENT PARCEL NUMBER: " ZONING: ACREAGE: oproperty <br /> ❑ PARCEL 0 'G-J1 z 7V !i /� t ontage drawn to scale. <br /> NUMBER Z. Y 7' ,"°'/'T 1 <br /> TOWNSHIP: O gto_ SECTION. 1/4: , 1 s/ iveway permits <br /> Y4,"� S z 7 �' /a/a: tate,county, own <br /> ADDRESS: ty ) <br /> Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 030.5-) i (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> T►FF REVIEW <br /> PROJECT DESCRIPTION: / , <br /> lr� e `� O (N C- E oning District <br /> arThis 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: PERMIT NUMBER: ( ura Address <br /> ❑SEWER SEPTIC f 8 o (.i ne existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> -a / 1 ❑ Wetl chain/ <br /> Sti and ( -. ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: q 1ST FLOOR: ❑ Erosion e. rat permit <br /> ! ` I s tart 3 3 S o 4 TOTAL SQUARE FOOTAGE: 4 apes •isturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filhn. :ccess). <br /> 5 3 a i Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► ♦ ♦ 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 Fo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank• n ne) <br /> 6. Is a location survey required? (see reverse) ❑Yes o Li Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MU BE SIGNED <br /> 54e-112(4/08) (Continue on Back)ST -► ♦ -► <br />