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SUPPLEMENT to,Web App#:;
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> pROPERTY:owtiER_INFORMATION:.. ._ ,,.12;:, W .. .. .:0 ", `v CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Ed u1 a r 4. /1 on k"I C 61 0 Zoning Status; CUP;
<br /> OWNER ADDRESS Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> I Z tZ rrgi i"t`\ 1) i l(q.yc A2.4 , � .e.v, l€4t (.(),• 53.E Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> -S6zZ .r 7� ifO ,:e co/n
<br /> c��`76 � � � C .ce 5 ha� � I2�o1 r !' u Site Plan drawn to scale
<br /> AGENT"INFORMATION, :cONTRA00R 1NFORMATIiN; r., and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> . D Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,State,Zip) ❑Setbacks
<br /> PHONE PHONE D Site Plan approval from
<br /> applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS •
<br /> D Floor plans to scale
<br /> :PROPERTY/LOCATION f INFORMATION ((http//aceessdane codane w�us/) .
<br /> PARENT PARCEL NUMBER: '//34-1/ CURRENT ZONING: ACREAGE: _ ❑Elevation of property
<br /> DNUM ER 07/Z -173- k — 1 3/4./ frontage drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> nC e • J e_ D 1 7 /4. NL1 /,/4. S' Driveway permits
<br /> ADDRESS: G1 /► n (state, county,town)
<br /> I2 2 F/'c,�r,e (}r (�4c�> RA'' er�irc(G� (,P�F -'-s-3 , Sanitary permits
<br /> CSM: LOT ✓✓ SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> •
<br /> PROPOSED PROJECT INFORMATION '`' STAFF REVIEW
<br /> PROD CT DE CRIPTION: _�� x " 4:
<br /> ,cte e rt `C Zoning D tract {
<br /> "'r ke r 'k 4'C;., ,.c
<br /> This project is a new building or structure. {
<br /> -D Permlttec�Use K , .
<br /> ['This project is an addition/alteration to an existing building or structure. 4
<br /> T t: F N:
<br /> SANITARY SERVICE: PERMIT NUMBER:
<br /> ,,-,:,,-`7,::.,-_,
<br /> Rural Address.t�
<br /> EWER SEPTIC `(nevtr/e`xisting)
<br /> HEIGHT IN FEET \ / NUMBER OF STORIES: (Not induding basement) = -,,:
<br /> 1 v ❑ Wetland/Floodplain/
<br /> � Shoreland`(altachment)
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches)
<br /> BASEMENT 1ST FLOOR —' EroslofControf p&rnit
<br /> 4, TOTAL SQUARE FOOTAGE: ,l 'E�slopesdisturbance
<br /> 1 'fihIin access ..s
<br /> 2ND FLOOR: 3RD FLOOR: 2c. 0 ^, o y ug#ee , ; '�}
<br /> ''t`�' _fl l�eview`Lhoc tiorVSurvey
<br /> ESTIMATED CONSTRUCTION COST: G4 ' "' -,�-5-Itn
<br /> --,and available o�itions4
<br /> (Please round to nearest dollar) "♦ --► ♦ '-► --► ♦ yl goo , 5.. *, _ _;.
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes Till o ['Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? Dyes j1' o Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? [Yes e o
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes ao
<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) Elves ®No VIOon't know
<br /> 7. Is this to correct a violation? Dyes VJNo
<br /> APPLICATION MUST BE SIGNED
<br /> riJ� (Continue on Back) -4. ♦ -9
<br /> 545-112(4/09)
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