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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to;Web App# . <br /> PROPERTY•OWNER INFORMATION , • <br /> „ -` _ 4 =_,_;'.: CU•TOMER TO PROVIDE <br /> OWNER NAME <br /> �►G�� r� d- bo r-b rei S ch ►1-e (I 1 Z_ Wing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) eed Restriction;CSM <br /> HOME�PHON k)3 nCELL PHONE c) kJ c-.. . ADDRESS anance(# ) <br /> /`'060 I Z S Plan drawn to scale <br /> _AGENT INFORMATION,: ;CONTRACTOR INFORMATION`.',`fl_;;. , M includes dimensions <br /> 0 AGENT NAME CONTRACTOR NAME <br /> L m Gu 7TOa 0 5 L L—C__ i e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> D12c cQ T wT 53 5 3 2 <br /> PHONE P ONE ❑ It Plan ap val from <br /> (�,a�)- S 7 r� 8- 3 "3 p licabl ownship. <br /> E-MAIL ADDRESS E-MAIL f DDRESS / ry F OOr plans to scale <br /> C ( k' 1 1 cs).)E I <br /> ? c ,c.r tp, <br /> ;PROPERTY/LOCATION:INFORMATION (httpa/accessdane co lane wr us/)_ .N;, Elevation of <br /> PARENT PA CEL NUM R: c CURRENT ONING: ACREAGE: . property <br /> ❑PARCEL 0 1 , l J 1.0 I� „0 <br /> NUMBER (� t ` p p frontage drawn to ale. <br /> `J <br /> TOWNSHIP: SECTI rr ` , 1 <br /> �j� T� / %4: N 1� wit: S w ❑Dnvewa rmits <br /> ADDRESS: 0 ,4a 1 _ \ n J (Stat OUnty, n) <br /> l/v , ,�1 (h Q�`I I }� ❑Sanita ermits <br /> CSM: LOT SUBDIVISION Ur BLOCIkOT <br /> -2.,D, 1Jor.J n (pu c,private) <br /> PROPOSED PROJECT INFORMATION _-''"-='.---, STAFF REVIEW <br /> PROJECT DESCRIPTION: "' t <br /> j' cd'ar�ii ®o rc�, d� �X/5t, _ cI- C IC L or ing District 4• <br /> ❑This project is a new building or structure. e^ `''w_t t F` <br /> Permltf �e� ,z <br /> p'fhis project is an addition/alteration to an existing building or structure. , r x f r <br /> SANITARY SERVICE: PERMIT NUMBER '0 Rura ddres : <br /> EWER JEPTIC i i(ne` exist <br /> HEIGHT IN FEET V NUMBER OF STQRIES: (Not including basement) , <br /> / I ❑ We WOLF Io pjaiOki <br /> Shore Ian "(attachment) <br /> AREA TO NEAREST SQUARE FOOT 4 _ . i <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ® `� - , r <br /> BASEMENT: 1ST FLOOR . .)` t � 3 0V Or OI It <br /> +, TOTAL SQUARE FOOTAGE y �slope jls: ,ance <br /> 2ND FLOOR 3RD FLOOR -1 J; fliiulg7acc $ e <br /> ,..---,, C) 0 ZT <br /> 5� Rewe nr�Loeati Survey <br /> (lease round CONSTRUCTION COST: ♦ ♦ -► --► ♦ ♦ $ M/1� (11 -and avallab�e optlons�^ <br /> Please round to nearest dollar 1 v y .• q; Y P a1•: <br /> • 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - 1es 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) ❑YesJo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► ♦ —► <br /> 545-112(4108) <br /> 0 .'"'"--4- r7 4 . . <br />