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) "7 S 00 x . c'7s. 3 + 5O114_SC) 4 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME rr <br /> 1O ( � . a^n t. L i has L- -5ri )1■15e) Ps oning Status;CUP; <br /> OWNER '..'ESS (Number,Street,Cv ,State,Zipl Deed Restriction;CSM <br /> 3 1 L i6tA.0 ga. ,et �)-, LO ► S3S34— t 33 i Variance(# __) <br /> HOME PHONE CELL PHON / E-MAIL ADDRESS <br /> La'8211- i i cog-q°I-i-gr'bf A/Dr? Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite PIa ' ing location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of w pti <br /> .....)/,:s., <br /> (City,State,Zip) ' (City,State,Zip) X Setbacks <br /> PHONE PHONE II!: Site PI oval from <br /> .p ' e wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> pa Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.d- . • .' /) <br /> PARENT PARCEL NUMBER: CURRE NIN ACREAGE: ,� levation of property <br /> ❑ PARCEL Q S/4 a-S u-at/n 6 — , -- frontage drawn to scale. <br /> TO N IP: SECTION: ■ rive ttS <br /> On '�- S _ %:—S 1/1/: Pi! <br /> ADDRESS: (sta , u town) <br /> IN n4 ltr .. E eZ�on ,w( s--35 <br /> Sanita rmits <br /> CSM: LOT :.IVISi BLOCK/LOT <br /> •r lan 804A LirK g l«k 3 list ct 1 (p c,p te) <br /> PROPOSED PROJECT INFORMATION REVIEW <br /> PROJECT DESCRIPTION: p <br /> r•o.;S-e -2>C ; St. s F iR ---- ---- %STAFF <br /> ning District <br /> . ❑This project is a new building or structure. ''7 Permitted Use? <br /> , 4"'his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> L! 'ural ' .. - <br /> --'EWER ❑SEPTIC '� (n;` /existin• <br /> HEIGHT IN FEET: NUMBER OF STORI (Not including basement)6/1 11 i -tiand/Fioodplain/ <br /> trT <br /> ' •Tr ;attachment <br /> AREA TO NEAREST SQUARE FOOT: L <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or po •• .:,_12 I—, • !-'f i,,� <br /> BASEMENT: 1 ST FLOOR: ErosionCOntr0) .' -14 Q L-i C 4 TOTAL SQUARE FOOTAGE:91 (slopes,disturban.D', <br /> 2ND FLOOR: 3RD FLOOR: f `J <br /> Ali im eview Surve <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 1 ` and Options. <br /> (Please round to nearest dollar) J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? -aYes Li No ❑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 . No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# __) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes -\No U Don't know <br /> 7. Is this to correct a violation? ❑Yes A4No <br /> j�. ."- --e---7 APPLICATION MUST BE SIGNED <br /> �" (Continue on Back) -i -1 <br /> 545-112(4/08) <br /> ,..-/i vy <br />