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500.0LEMENT***0041$0.-k.
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> PROPERTY-OWNER INFORMATION ,`._., .Z44„_ ',-. r _ ; ";r , : - Cu-TOMER TO PROVIDE
<br /> O�R NAM
<br /> 1--`L, 4 V k`'`` LA- -Q-C 1 ning Status; CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> g3O LA uy Al S h �l eed Restriction; CSM
<br /> ���� '�' rrc� t� ariance(# )
<br /> HOME PHONE CELL PHONE , E-MAIL ADDRESS •
<br /> teat 83'1• //3g ,�, `,5'/) t 3 a Y'4c L,bl't*ere ■lviA)L. (6 ite Plan drawn to scale
<br /> AGENTiNFORMATION CONTRACTOR_INFORMAT,ION..'` ;;t U4r and includes dimensions
<br /> ART NAME CO TOR NAME
<br /> W EN kAaS DQS,,J4'/CatiS1', C, 4/761 e ' Site Plan including location
<br /> AGENT ADDRESS v CONTRACTOR ADDRESS of well/septic
<br /> tidg3C JALZ,4 . ,
<br /> (City,State,Zip) (City,State,Zip) Setbacks
<br /> PHONE PHONE lAr � ❑ ite Plan royal from
<br /> kos-- --/n---z&--71 pplic e township.
<br /> E-MAIL ADDRESS E-MAIL DDRESS �� •
<br /> R�rC tor-,e 4dc , u,�,,f,,.4'1 Flo•r plans to scale
<br /> 'PROPERTY_/LO_CATION INFORMATION (http l/acces�dane co lone w us/)I -e
<br /> PARENT PARCEL NUMBER: CURRENT/TING: ACREAGE: - evation of property
<br /> III NUM ER 6S Q���1- � V ^ �3 _ 'ont.ge drawn to scale.
<br /> TOWNSHIP: �.p SECTION: �� D iveway permits
<br /> j),,i a�f s '/a: �'�4: — (state,county,town)
<br /> AD / A U �` b J
<br /> K�Q� il - itary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (8 0IIC,private)
<br /> 1376'0
<br /> PROPOSED PROJECT INFORMATION , -"_- _':; x STAFF`'REVIEW
<br /> PROJECT DESCRIPTION:
<br /> /1k GL) a4364 p 4'v 1 r
<br /> 11 Q V t1r(.. L onmg Dlstnct r
<br /> This project is a new building or structure. �k `- , ° ' ` ` ,g - .
<br /> b Permltfed Use?
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PE NUMBERj'�` r Address
<br /> ■.EWER ri+•EPTIC 0; CQ �. (new xisting) _
<br /> HEIGHT IN FEET (x NUMBER OF STORIES: (Not including basement) ® land/I'IOOdp)aln/
<br /> horeland(attachm ent) ,•,
<br /> AREA TO NEAREST SQUARE FOOT: _ f,._
<br /> (Outside dimensions including unfinished area,atta e a s and above grade decks or porches) ^�
<br /> ` ' p ® roslonControl p mit
<br /> BASEMENT: 1ST FLOOR: - x
<br /> Z ltZ ' ,, TOTAL SQUARE FOOTAGE: 4, ' �slopes`dlstuyrbance
<br /> �1z w + fllllfTWCesVrA
<br /> 2ND FLOOR: 3RD FLOOR: 44.7 i* *� ;A ,C
<br /> a F7evlevvltatop Survey
<br /> ESTIMATED CONSTRUCTION COST: a "" ` `
<br /> nda ly.: le options
<br /> (Please round to nearest dollar) ♦ ♦ ♦ � ) F?'� ty
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? R, es ❑No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? e es Opp,o ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? ∎4 es it o
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - ❑Yes ZI,, o
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan i'if none)
<br /> 6. Is a location survey required? (see reverse) ❑Yes IJINo ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes NI o
<br /> t \ APPLICATION MUST BE SIGNED
<br /> sa545-112 itz(4/08) $. t \ 1 (Continue on Back) —I. —► —11.
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