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F? 3-.3-4/ - c
<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to Web-App#.
<br /> PROPERTY OWNER INFORMATION a,,;; ,_ z=_,:, &Wd ; `'bY, a .,�. >,• r.,:'f_: ":" CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Est -e 64ti nr--1-f t'Lc- L, t L ❑ Zoning Status;CUP;
<br /> OWNER ADDRE (Number,Street,City,State,Zip) Deed Restriction;CSM
<br /> /J37 111( 14,,,,..-{ L',1,1`e-- Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR;INFORMATION ,._. , , and includes dimensions
<br /> AGENT NAME / CONTRACTOR NAME
<br /> I')S /'t0,0 ke✓ t ukerw) 1,rl�,4e.i..S ❑ Site Plan including location
<br /> AGENT ADDRESS / CONTRACTOR ADDRESS of well/septic
<br /> W1.3 Lott .jye vh
<br /> (City,St te,Zip) (City,State,Zip) ❑ Setbacks
<br /> /14/ I-a✓lAclei v✓I 5-3SSi
<br /> PHONE / PHONE • ❑ Site Plan approval from
<br /> applicable township:
<br /> E •IL ADDRESS jj E-MAIL ADDRESS
<br /> K'�/ , -h - • v i/)e ,.,,t ❑ Floor plans to scale
<br /> PROPERTY/LOCATIONINFORMATION ':;(http://accessdane co danewi.usn ` ❑ Elevation of
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property
<br /> P rtY
<br /> ❑ NUMBER o 5-12-Err -2(1/1/-2 ,4 j frontage drawn to scale.
<br /> TOWNSHIP: /
<br /> 4/ r, J ZS- 1) 1/4. •/( 4%: SF— ❑ Driveway permits
<br /> (state,county,town)
<br /> ADDRESS: `7 )
<br /> -36 2 Z 0,k z SAorz Pr ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION s;
<br /> PROJECT DES RIPTION: C /-01.114_ I �_ E, -
<br /> �°'�'�� / r-)5/...e___ 1'[ r.,7,1*P a4 l4t0,it-�, -:-•T::: :,,-
<br /> ❑This project is a new b ilding or structure. > --.-4, --,:-
<br /> ❑This project is an addition/alteration to an existing building or structure. ° ; z
<br /> I is ter` .4 - x
<br /> ,SANITARY SERVICE: PERMIT NUMBER:
<br /> SEWER ❑SEPTIC ' , t
<br /> ` -.a*fa -`ms:-'. z , w- ,,.
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) r
<br /> � ° it�s
<br /> AREA TO NEAREST SQUARE FOOT: , q
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' �'
<br /> BASEMENT: 1ST FL� �_ e s� ����
<br /> 4, TOTAL SQUARE FOOTAGE: ,�, ® rR ui- ,
<br /> ,
<br /> 2ND FLOOR: 3RD FLOOR: A
<br /> v Z77b _ .G 1,,
<br /> ESTIMATED CONSTRUCTION COST: -'6
<br /> (Please round to nearest dollar) -* -∎ "i "� -4. "♦ $ / tJ � s�
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑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 ❑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 LI Don't know
<br /> 7. Is this to correct a violation? ❑Yes ❑No
<br /> Z® .a�
<br /> APPLICAUT B.+E(Continue on TION Back MS) -0 S-►N-
<br /> 545-112(4/08)
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