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, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to.Web-App#- <br /> PROPERTY OWNER.INFORMATION ;_: '-„4-0,,?; -00 r;; .L.._: <1 - - : CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> RO ER V RI C1C Sc) ❑ Zoning Status;CUP; <br /> OWNS ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> (p51-7 1-1 tPtt R 1 Rbv}t) Variance(# ) <br /> OME PHONE CELL PHONE E-MAIL ADDRESS <br /> te Z6-5-952 2.1- (604A ❑ Site Plan drawn to scale <br /> AGENT INFORMATION - CONTRACTOR INFORMATION t , — and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 'Tb M Gov E S riE/AN Ira. i 94 Row 130ILOC(tS ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) <br /> 41900 NE SSE t: t),2 1 0 E . <br /> (City,State,Zip) ❑ Setbacks <br /> T4-0 tSVIL.�E'�. 6t/T- 5-3 54 t. <br /> PHONE PHONE ❑ Site Plan approval from <br /> t7 51—/„ j2-6. 2_ bog 1/52 - 69 /35— applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane:codane.wi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> 1",3„PARCEL BER c12.243'9 000 Cp frontage drawn to scale. <br /> NUM <br /> TOWNSHIP: SECTION: <br /> A L i3'Io 1/4: IA : ❑ Driveway permits <br /> ADD <br /> i-RESSS: <br /> • <br /> LOT p SUBDIVISION BLOCK/LOT (state,county,town) <br /> J 9 L) b o t R e4D ❑ Sanitary permits <br /> CSM: <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION;! 1 '. <br /> PROJECT DESCRIPTION: ”" -" , , <br /> To 8 LL) 4 NEw D, <br /> Ill This project is a new building or structure. l Z <br /> ❑This project is an addition/alteration to an existing building or structure. r t - <br /> SANITARYSERVICE: tr t-r e arr. <br /> PERMIT NUMBER: 3 ,��.:F,f F,,.$ ,.-` <br /> ❑SEWER 0 SEPTIC '�, �r&l .- ' • . <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> 162 '0 " 1A)•� - ,, <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r k,atom <br /> ®� 'l r� �r <br /> BASEMENT: 1ST FLOOR: F� � �,;; <br /> 2-I 3 (8 2) 3 0 4, TOTAL SQUARE FOOTAGE: j �l''',1"','.=: I,J4t L l+ .`: <br /> 2ND FLOOR: 3RD FLOOR: <br /> I-1 7-r? (p <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ r .Ai �® g, sty <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? ❑Yes to ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes R.-No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes No <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? LI Yes po No <br /> AICA MUST BE ED <br /> 545.112(4/08) <br /> (Continue PPL on TION Back) —► —SIGN► —0 <br />