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;::suP.IPLEMENT#o•Web App-.# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> `PROPERTY OWNER:INFORMATION _ CUSTOMER TO PROVIDE <br /> �. - .� � x'.t G ER VID <br /> OWNER NAMy� <br /> QQ ill A Nt [> SQt 1 Zoning Status; CUP; <br /> OWNERADORESS mber, ttrt,City,State,Zip) Sys Deed Restriction;CSM <br /> 3 3 9 3 Co.Co (2. M Al, M �Ailt-A'ID , LUZ 3 Variance(#11 D 47 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> :58.- as-7 ) 5-71-61.;s 3 TM 4-LFx tk/rim of il-"'.c4AN. Site Plan drawn to scale <br /> AGENT-`INFORMATION ,• =CONTRACTOR.INFORMAT,ION_' ,;; and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> . *Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 10 Setbacks <br /> PHONE PHONE 10•Site Plan approval from <br /> applicable township. <br /> E-MAI L ADDRES S E-MAIL ADDRESS • <br /> 4 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION ` htt /laccessdane so da_ne wr us ',' <br /> I- P 4 "� Li Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE. _ <br /> El NUMBER 6 Ib—01'3'+9*5'St'.. R(♦1 �1 , 18 frontage drawn to scale. <br /> TOWNSHIP: SECT ON:i'v l <br /> D V A) '/4. V ,/d/4. ,SIN) ❑Driveway pe Its <br /> (state, c nty,to n) <br /> ADDRESS: �3 <br /> ' (..._.'s O IA ',( ,� H S anita ermit <br /> s <br /> CSM: 9'[ LOT to, I SUBDI SION BLOCK/LOT (P u ' P rivate) <br /> ► <br /> PROPOSED.PROJECT INFORMATION - .- r AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> c 11 onin Dlstnct f <br /> . 't'fhis project is a new building or structure. ermitted '& iJ <br /> ❑This project is an addition/ eration to an existing building or structur . - v -� := r <br /> SANITARY SERVICE: PERMIT NUMBER: t p\..) ® ralA.sres < <br /> EWER EPTIC lr `` new/e sting <br /> HEIGHT IN FEET NUMBER OF STORIES of including basement) <br /> C,A/L Wetland/Flo▪ plain/ <br /> Shorela :{attachment) <br /> AREA TO NEAREST SQUARE FOOT r: _ <br /> (Outside dimensions including unfinished area attac da(ges and above grade decks or porches) J r <br /> 0 EroslonCon permit <br /> BASEMENT 1ST FLOOR: f �rl <br /> 341,;(1A. 4, TOTAL SQUARE FOOTAGE j � - slopes, turbance <br /> "` -� "'.s« °.-mot' s <br /> 0'54-Jilin_B Ccess) <br /> 2ND FLOOR 3RD FLOOR .g '/ O O 4 7 _sfi �Yt <br /> ReviewiL,oeafion SU..vey \vtrv, <br /> ESTIMATED CONSTRUCTION COST / and available• optlons� <br /> (Please round to nearest dollar) '♦ ♦ -► ♦ ♦ -► $&St/00 (� „ •.°r s; <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? s *Jo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es o Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? so <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - es <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#11 0147 ) (leave blank' none) <br /> 6. Is a location survey required? (see reverse) [sqi'es ffj! 0 ODon't know <br /> 7. Is this to correct a violation? t'es OJo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/06) (Continue on Back) —► —I- <br /> . 44 < � . —I. <br />