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ZONING PERMIT APPLICATION wwcountyofdane.com SUPPLEMENT to Wet}App# <br /> w. <br /> PROPERTY OWNER INFORMATION ,_..i:; :';' id,;.A;`.��.,-e -, _ .,,-. <.,,._{ ; CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 146tk,g g TctZ ❑ Zoning Statu , UP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Re Iction;CSM <br /> .02$22 I-I 67i.1 Sf f u E 20 k 7"1/ ria (# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS �\ C„q ��, <br /> ._ �C< �i tt�iF� 'jr Site Plan drawn to scale <br /> AGENT INFORMATION , CONTRACTOR INFORMATION r ,-. nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME �,, r,� <br /> C f f 79LY S C7 �: t ig y ite Plan including location <br /> AGENT ADDRESS / CONTRACTOR ADDRESS of well/septic <br /> tp c w'lrvaiaQuv, / RP <br /> (City,State,Zip) (City,State,Zip) a / Setbacks <br /> PHONE PHONE 6yu�/ 1 S3W% ❑ Site Plan royal from <br /> a plic a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION:INFORMATION+;(http://accessdane.co.dane.wLus1) Elevation of PARENT PA��RggCE NUMBER: CURRENT ZONING: ACREAGE: P P <br /> ❑ NMB <br /> UER O2 Vei o ro e <br /> o6�O-c n- col I E -/ 1 j col frontage drawn scale. <br /> TOWNSHIP: OU` V SECTIQN: ❑ Drivew ermits <br /> /j7 1�: �,� t�t�a: � W <br /> sta ,coun ,town <br /> ADDRESS: c18�� �n ` \J Q ( town) <br /> v(J ❑ Sani permits • <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pu IIC,private) <br /> PROPOSED PROJECT INFORMATION, �_ - �F r <br /> `PROJECT DESCRIPTION: <br /> 0 'If P 1 t Q i N& 1.4 IA/Ol e■ ,' S' j 'yfyi r „ L`.' 'J..s ;47;:::-- <br /> ❑This project is a new building or st cture. °%,:s:`' <br /> This project is an addition/alteration to an existing building or structure. k 4: ■ <br /> NITARY SERVICE: PERMIT NUMBER: 'h_ €, i ',4'_IF„4 .( t ,4 <br /> ❑SEWER SEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) " <br /> I u.vtp, <br /> AREA TO NEAREST SQUARE FOOT: '`7,' r <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) -f- f <br /> �t i� <br /> BASEMENT: 1ST FLOOR: 4.a e ® S <br /> j 1? 0 0 4, TOTAL SQUARE FOOTAGE: 4, y, g� , Iiit� � <br /> t <br /> 2ND FLOOR: 3RD FLOOR: � 1 I <br /> Y <br /> ESTIMATED CONSTRUCTION COST <br /> (Please dollar) ♦ -� -► .0 -► ♦ 1 Q Q '� -' ®eels <br /> Please round to nearest dollar 4 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Fi Yes KNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? AYes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes KNo <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) ❑Yes ❑No 'Don't know <br /> 7. Is this to correct a violation? ❑Yes ZisNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br />