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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 /> 0 C \\Q.A K \--\R S I C,y-- ❑ Zoning S us; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed striction; CSM <br /> y3C7"j RcA—V1ghA %A InIi\ 10t.Ai\1 I hQ._ RCi Var. nce(# ) <br /> HOME PHONE 0 ELL PHONB+F Pi ivneky.,1 E-MAIL ADDRESS <br /> cos 3-C- 535. C„Q2,1,35',q'S-ya c-°l1"eevi.11ck51'w-P 3th5' <Z INN 'X Site Plan drawn to scale• <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dime as <br /> ns <br /> AGENT NAME CONTRACTOR NAME ,and ; CNN - <br /> �Ue.-rr�x c'.5 O W ham(" Sg1-n.t, C15 OW 14-cv('— Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City.State,Zip) (City,State,Zip) 4' Setbacks <br /> PHONE PHONE ❑ S' e Pla pproval from <br /> ppli le township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS o U <br /> oor plans to scale�„J` <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.ciane.wLus/) of property t D1 ` <br /> PARENT PARCEL NUMBER:�] '/ CURRENT ZONING: • '=AGE: <br /> ❑ NUMBER ��' -3°� 1�3 7D-1 R�— 5•O frontage drawn to le. <br /> TOWNSHIP SECTION: c 10 Drivewa ermits <br /> 11 v) 3 a %: '/4'/4: s <br /> (sta , county, •.'n) <br /> ADDRESS: �-, <br /> '43 ''1 RLkilathA 1.� h Itgoo.)hl1►...c Rd <br /> ❑ Sanit. permits <br /> CSM: O a S p LOT I SUBDIVISION BLOCK/LOT (p.'tic, <br /> private) <br /> PROPOSED PROJECT INFORMATION TAFF REVIEW <br /> PROJECT DESCR�IP/TI N:`/ /' � �y ``,.i i r Jt O KD `� /� / l� /0/ fQY�� o • ing District <br /> . u�This project is a new building or structYo: fw\'i'y l a' )e 14 ' <br /> ermitted Use? <br /> t4This project is an addition/alteration to an existing building or structure. Goorgc <br /> SANITARY SERVICE: PERMIT NUMBER .ad)( 3 0 ❑ Rural r••u , <br /> ❑SEWER Ni SEPTIC (new/- .isting <br /> HE T W FEET i NUMBER OF STORIES: (Not including basement) <br /> I / (A)DA i ❑ Wetlan oodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shor and (attachm nt) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ❑ ErosionCont permit <br /> BASEMENT: 1ST FLOOR / <br /> ^qty-I�i� /©Q q j TOTAL SQUARE FOOTAGE: 4, (Sl es, Urbance, <br /> 2ND FLOOR: 3RD FLOOR: ( /OO fil ngess) (�1 eview Location Survey N <br /> ESTIMATED CONSTRUCTION COST: Q� and available options. <br /> (Please round to nearest dollar) — - 1 ♦ $ i �° i 0'0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 4 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes X No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ®No-L M)a, tom_• <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 14 Yes ❑No y ta,.( w ,,,,,.. <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none)o� 11 i o fry,, <br /> 6. Is a location survey required? (see reverse) ❑Yes [ No ❑Don't know 14 <br /> 7. Is this to correct a violation? J Yes 4 No p4rrn'1 r # <br /> -2_pa00V)V, <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 -+ -+ <br /> 545-112(4/08) <br />