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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT#o'.web App;#:: <br /> 'pROPERTY`OWNER_INFORMATION . ., 1-3 - - <br /> ' CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> EL12.1x >1.1L a c:!SCtr--wzA 1 'Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Z.1 1 .--t)i',v t^1 r4R ' 1 S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 14Site Plan drawn to scale <br /> AGENT.INFOR ill ATI`ON ,._ 'CONTRACTOR INFORMATION_' ., r g ,`., and includes dimensions <br /> ' AGENT NAME CONTRACTOR NAME <br /> M ICI-IA e CON5(9-C. VC) Lite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS <br /> of well/septic <br /> 7 2 �C��'T LL c---/Z- ST <br /> (City,State,Zip) (City,State, <br /> Zip) �-�°•/ etbacks <br /> PHONE _ 0 N > t /LL�( 1 <br /> PHONE �q 4ite Plan approval from <br /> 60g-9 Z(_ 7 -V applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS • <br /> PROPERTY/LO_CATION INFORMATION -_ F <br /> [door plans to scale <br /> (Inttp/laccessdalrie co'd_ane w�.uSn�-,�..�z�� • <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> PARCEL frontage drawn to scale. <br /> NUMBER a61 a"mil—Z,l`l�3 <br /> TOWNSHIP: SECTION: <br /> .— )tiJ1^1 OCI 1/4: � WA: Nvsl iiliAriveway permits <br /> ADDRESS: J (state,county,town) <br /> 2cZ.?=•\ '°-- • . CA ''- II; Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> - ,. _ STAFF REVIEW <br /> PROJECT DESCRIPTION: � ,: <br /> z DET�RI05.171nP»ma C.. iRso� 1rL C-Y. = ontri Distnct r <br /> • ❑This project is a new building or structure. �" fir' - k . <br /> `�Permttfed Use? 1 '-. <br /> This project is an addition/alteration to an existing building or structure. f,�4y� .' = <br /> SANITARY SERVICE: PERMIT NUMBER: LVI RUraI Address ti _ <br /> EWER [EPTIC '�(ne /`xisting) <br /> HEIGHT IN FEET / NUMBER OF STORIES: (Not including basement) x9 <br /> 3 t 0 We a� adplain/ - <br /> AREA TO NEAREST SQUARE FOOT Sh rel 440-65ent) F <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) e r. i a 1 <br /> Ero ` "4 ontrof mlt <br /> BASEMENT: 1ST FLOOR: -® lam. <br /> 4, TOTAL SQUARE FOOTAGE: 4, -JSI ,r@ • _urbance <br /> w- <br /> 2ND FLOOR 3RD FLOOR: 1 filflrg7a eSS <br /> Y-�- -3 s n.. is 1 <br /> :t Rev` �.- bn SUrvey' <br /> ESTIMATED CONSTRUCTION COST r '" *?' -rte: > <br /> (Please round to nearest dollar) end's 5',.,{ .fions� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Res ONo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 1_4res ONo ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Rees ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - 0Yes [,(io <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) QY s [v to ODon't know <br /> 7• Is this to correct a violation? s ONo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► -9- <br />