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<br /> ZONING PERMIT APPLICATION www.countyofdane.com ,SUPPLEMENT to Web-Apo#
<br /> PROPERTY OWNER INFORMATION`,a.,,,,= .,z=__:' !;?� t: ,` .,. -2,.: < rt :- :w' CUSTOMER TO PROVIDE
<br /> OWNER NAME _ (�
<br /> U C�.uv 9= c {k,'� I `C'YYv(l-1/�S [ 'Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> Deed Restriction;CSM
<br /> -3 1 S-'3 00 K 1,cn t')0 ��( S1 L 'l` l�) I Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> % 39 J Si ite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION -+ nd includes dimensions
<br /> AGENT NAME CONTRACTOR NAME ()
<br /> C� V.cLt +� . Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR AllESS of well/septic
<br /> 30-'1-1- v,L)c iL&C1\ S r)'`1
<br /> (City,State,Zip) (City,State,Zip) w l Setbacks
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<br /> PHONE PHONE �6 ASite P approval from
<br /> ,J �' 3 l" apprcable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danewLus/)
<br /> PARENT PARCEL NUMBER: CUR T ONIJ NG: ACREAGE: Elevation of property
<br /> ❑ PARCEL �//_-)Q.) bg7 NUMBER frontage drawn to scale.
<br /> TOW HIP: SECTION:
<br /> 1/: Si 1/4%: �(j,J M Drive ermits
<br /> ADD19:s O O qk\J c� ip� (sta ,c nty,town)
<br /> S� C Sanita ermits
<br /> csM: q) LOT SUBDIVISION _ BLOCK/LOT (publ' ,p ivate)i/i
<br /> PROPOSED PROJECT INFORMATION - ? s K ��',
<br /> PROJECT DE RI PROJECT ,F ,, 3 =< "I' ' �
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<br /> ,"This project is a new building or structure.
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<br /> ❑This project is an addition/alteration to an existing building or structure. !---zfr-'7 x -
<br /> SANITARY SERVICE: PERMIT NU 2 � ter °° �
<br /> ❑SEWER ,SEPTIC 1A ck4-.e s
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<br /> HEIGHT IN FEET: NUMBER OF STORI S. (Not including basement) --4:1,.: : - , '
<br /> i� S ;jam_ ° ,�,t% , ) 1`
<br /> AREA TO NEAREST SQUARE FOOT: 7 'z
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �°
<br /> BASEMENT 1ST FLOOR• Tg ` � �=
<br /> 4, TOTAL SQUARE FOOTAGE: 4, ,? ° r
<br /> cy „bra
<br /> 2ND FLOOR: 3RD FLOOR:
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ --► --► ♦ k-® xl 3rd
<br /> (Please round to nearest dollar) ` LS':-°:,:f..4-',"-,‹-774.,''...4.1.-- _-,=,' ..,,t=.,
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes f\lo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement') Yes LI No
<br /> 4. Has there been a zoning permit•issued forihis property in the past 5 years? DYes 'QNo
<br /> 5. Is this project associated with a`rezone/CUP/variance(petition/appeal# ' °) (Idave blank if none)
<br /> 6. Is a location survey required? (see reverse) ['Yes No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes '// Dlo ,; ,
<br /> APPLIC ATION MUST BE SIGNED
<br /> (Continue on Back) -* -► -►
<br /> 545-112(4/08)
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