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SUPPLEMENT#ei:wob App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY,'O WNER INFORMATION .. . ; . *z - ,::�' ` CUTSTOMER TO PROVIDE <br /> OWN NAME . <br /> =—CA w�\v\ l'-k -le '(Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street City,Sta e,Zp) , Deed Restriction;CSM <br /> SCICt 0-:-+\/ 1'l� , �V"U �SCJ�\11Sjw� 5'35f38 V riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> W 1 �'140q C( ' 44 J t O f-\6 PA L S•n£- <br /> Bite Plan drawn to scale <br /> AGENT INFORMATION 'CONTRACTOR INFORMATION.,::_;,t; _; and includes dimensions <br /> AGENT NAME CONTRACTOR NAME / C <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) I ,Setbacks f <br /> r <br /> PHONE PHONE ❑Site Plan ap roval from <br /> 4 pli,b1e township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Nf Floor plans to scale <br /> PROPERTY/LOCATION INFORMAT_ION_ httPi/laccessdane Co da_ne wi usn *;--,;� .� Elevation of prop <br /> PARENT PARCEL NUMBER: CURRENT ZO NG: ���------ ACREAGE <br /> ElPARCEL "+a 80'7-103-M 0 , _ i �� frontage draw o scale. <br /> NUMBER � '�(` <br /> TOWNSHIP: t� SECTI1N�l ' , 1 n <br /> E r l v ,�4: �V`i 1,Y4: l v r n Drivew 'permits <br /> ADDRESS: N (stat , county,)n) <br /> ` CO. V � V <br /> El Sanitary rmits VI <br /> CSM: LOT SUBDIVpION )BLOCK/LOT /(publi rivate) <br /> PROPOSED PROJECT INFORMATION t <br /> PRO kCe CTD CRIPTIggN: ` I STAFF REVIEW <br /> +0 f GCam. � S1� (9D1C �a oriing Dlstnct r <br /> ,r. 1 -s <br /> . ❑This project is a new building or structure. ,7::"� r <br /> Permltfe e? �. <br /> This project is an addition/alteration to an existing building or structure. , , : Y <br /> 1 � . x_ N <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rtii-A •di c'e[}EWER TIC (11 _ (new/ xlsUn <br /> HEIGHT IN FEET: ^ '� NUMBER OF STORIES: (Not including basement) <br /> yl�r/ , <br /> 1 :❑ Wetland/Flo plalrK <br /> Shorelan attachment) <br /> AREA TO NEAREST SQUARE FOOT t.- - <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) lit t . f , <br /> BASEMENT 1ST FLOOR: t\ 'J ❑ �rOSlO O-t- PP RIIt'x <br /> �� 7'yo j, TOTAL SQUARE FOOTAGE 4 op�es,disturbance <br /> 2ND FLOOR 3RD FLOOR ripfiiiirig/acceSSM <br /> flrRevleaa co afibn SUrvey A //��` <br /> ESTIMATED CONSTRUCTION COST: L� _� ,and available options* �/ ,`,// <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ �)OQ lJ .Y _ S;:iri z ,- , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? QYeslo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes Jlo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? FA es Olo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? a es QNo <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 0 o ['Don't know <br /> 7. Is this to correct a violation? Elves M o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545112(4/08) - . <br />