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.4 • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /� <br /> Gi OIy f The/Pi, C�6-7-c tPl7 M.- Dal, 16,4 .l Zoning Status; CUP; <br /> OWN RADDf2ESS (Number, reef,city,Start,zip) / ! �� Deed Restriction; CSM <br /> / 95'2. , ,4 rll a-i—A pd V er'1G, S3 S_ 73 Variance(# ) <br /> HOME PHONE CELL PHONE • E-MAIL ADDRESS ( <br /> 6. g3 Z— 9L/11 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AG�T,ZAME J/ � _ CONTRACTOR NAME <br /> / � ^ //{{ G Site Plan including location <br /> c AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (Ci State,Zip) (City,State,Zip) f.'betbacks <br /> fipty(6 o, 3 Cl' � PHONE - c -• ...royal from <br /> � 7— � .. !cable • nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Moor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p P y <br /> ❑ PARCEL A&07_,26,Y 965Z_Z A- 1 frontage drawn to scale. <br /> NUMBER ( � �j ��`– <br /> TO SHIP: ` SECJJOjJ: _ <br /> r ?act I.e 2c '/4: S '/4'/4: S� Driveway permits <br /> ADD ESS: (state, county,town) <br /> 19 A Ad 1074 RC1 U'e7 o _ W_L s-35—t7 <br /> CSM: LOT SUBDIVISION BLOCK/LOT unitary permits <br /> _---- (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: ( EVI(EW <br /> 1z—5 t 0 .--Y1--) / ,--c____ A CC • `f 6LDG. - ST-o,z,q ct E 5E Zo incg DI 7,4,t;':, <br /> ZgoicA.iThis project is a new building or structure. itte= <br /> CI This project is an a • ion/alteration to an existing building or structure. , <br /> SANITARY SERVICE: 2)// PERMIT NUMBER: Rt�rali ass <br /> C/ { W <br /> L I SE R PTIC �r (nevuC IS <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) <br /> (U, Z / lan oodplaln! "°. <br /> Sharetati attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ' $ tr <br /> Ipermit <br /> BASEMENT: 1ST FLOOR: ( 161 6i e •'' rban 49oD Z0 5 + TOTAL SQUARE FOOTAGE 1 <br /> 2ND FLOOR: 3RD FLOOR: 1Is t <br /> ESTIMATED CONSTRUCTION COST: <br /> U Vletuf Rev c o tton urvey j p. <br /> t bCe options <br /> (Please round to nearest dollar) ♦ --► ♦ ♦ ♦ ♦ , �- <br /> 80v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 173 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes <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) ❑Ye ®N ❑Don't know <br /> 7. Is this to correct a violation? CI Yes No <br /> o-/--)-( 6 14 , -).>, (J( r APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ - <br /> 545-112(4/08) )., J a L t ( . <br />