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V <br /> Li 46' ( " --- , . <br /> ZONING PERMIT APPLICATiO www.countyofdane.com SUPPLEMENT to web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> V - . (2.-i(kl 6t.il 4 L°L-- (- ❑ Zoning Status;CUP; <br /> OWNER ADDRESS(Number,Feet,Cl te, ) <br /> X�` Deed Restriction;CSM <br /> IC 01 ~ 1 1,0 �-1 . (1 i i l4 f 11,l 5 .1/ Variance(4 ) <br /> HQMPItiO�,.J CELL PHONE EMAIL ADDRESS <br /> it �C 11 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 'CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME (�, CONTRACTOR NAME <br /> 5'4111 E fi A b V e ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of welt/septic <br /> • <br /> (City,State,Zip) (City,State.Zip) ❑ Setbacks <br /> PHONE • PHONE ❑ Site Plan approval from <br /> _ applicable township: <br /> E-MAIL ADDRESS EMAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:gaccessdane.co.dane.wi.nsf) ❑ Elevation of property <br /> PARENT PARCEL NUMBER; CURRENT ZONING: ACREAGE: <br /> 0 PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: 1/ V4Y: ❑ Drive �Y <br /> ADDRESS: I t\,( ` ems 4 {stn :, F•• Y down <br /> 7 b '1 DC w ert. ❑ Sank ',a . i <br /> cem: I LOT SUBDIVISION BLOCK/LOT (public,p`%,- e) • • <br /> I 'r°Uoa I--o 110 <br /> PROPOSED PROJECT INFORMATION - .. <br /> PROJECT DESCRIPTION: 6' C <br /> t 1 <br /> . ®'This project is a new building or structure. <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> -- SANITARY SER,-V,I . —_EERMII :_ _ <br /> NUMBER:. <br /> ❑SEPTIC rr -- <br /> HEIGHT IN FEET. 3 D 1 JJUMBER OF STORIES: (Net including basement) <br /> AREA TINEAREST SQUARE FOOT: <br /> (Outside dimensions including unflnish area,attached garages and above grade decks or porches) • <br /> f c..., BASE MENT: 1ST FLOOR: <br /> 1(,, 13 9 `•} 1 .1 ( () +. TOTAL SQUARE FOOTA =• <br /> 2ND FLOOR: )b5 \C S2 J ( i "J� <br /> . tIl{ IIJJ �i/ <br /> ESTIMATED CONSTRUCTION COST' ( CO <br /> (Please round to nearest dollar) ♦ '� '� "� I l0 • <br /> '1. The roe is <br /> • within 300 feet of a stream or 0 0 feet�frorrt ap ltd o la ?c —0 Yes �No I Don't know <br /> property rtY Po <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes L'No 0 Don't know <br /> 3..Have you talked with the township about your project and are they in agreement? dyes ❑No <br /> 4. Has•there been a zoning permit issued for this property in the past b years?.. gYes 0 N <br /> 6. Is this project associated-with a rezone/CUP/variance(petition/appeal# ) (le9ve blank if none) <br /> 6. Is a location survey required? (see reverse) gYes ❑, No 0 Don't know <br /> 7. Is this to correct a violation? ❑Yes t No <br /> i, <br /> APPLICATION MUST BE SIGNED <br /> 545.112(4/08) (Continue on Back) -'• + -o- <br /> I <br /> 1 <br /> 1 <br />