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) / Gtr .°/ s4-s 138 e <br /> ZONING PERMIT APPLICATION ww .countyofdane.com SUPPLEMENT to Web-App# <br /> w <br /> PROPERTY.OWNER;:INFORMATION .,:: .,=-,: '. t ; 4,0 ;, ,.4_.''S `,: .- `:4 CUSTOMER TO PROVIDE <br /> 9WNER NAME <br /> /e/P .SA�41 " /V o f 7W,2dP .N Zoning Status;CUP;�y. <br /> /OW ADDRESS (Number,Street,City,State,ZiZiip)) /� Deed Restriction;CSM s <br /> Io/L_Ho/ 4e2 CELL LiaHr,/ /G o . Cr/G D4/4 a s .53,59...? _ 'ance(# r ��� <br /> �0e�f - ' ' • Site Plan drawn to scale <br /> AGENT INFORMATION. ;: CONTRACTOR INFORMATION ;r , 2 ; .nd includes dimensions <br /> AGENT NAME /' CONTRACTOR NAME <br /> '. /G/i�i C;/G(9if-4-/ _eoo 4, 1 = Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS •f well/septic <br /> o tor. res La • <br /> (City,State,Zip) (City,State,Zip) PK Setbacks <br /> PHONE PHONE 21 Site Pla approval from <br /> d a,g-- f6 ,4g yS7 _,pli le township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION;INFORMATION (http://accessdane.co.dane.wLes/) Eleva property <br /> PARENT PARCEL NUMBER: CURRENTjZONING: ACRE1AGE: P P rty <br /> A N MBER ��o7W! ,7626/7 ,q—t -•1 _t1 front awn to scale. <br /> TOWNSHIP: SECT <br /> P/1r 2ese 1/: s-Q '/a'/:__o_►t'j___ Pc Driveway permits <br /> ADDRESS: E (state,COUn i <br /> J G <br /> O f Fi'/z 7/1 / D Sanit <br /> ary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION. A/V <br /> PROJECT DESCRIPTION: /� •1 7 -.. . <br /> AA l r A-id l V i c,L?'✓✓ . f TL S p ~'- <br /> W This project is a new building or structure. , ., p�p,, K-- h� <br /> ❑This project is an addition/alteration to an existing building or structure. - - : - <br /> SANITARY SERVICE: PERMIT NUMBER: �' °' ,s;ay <br /> ❑SEWER SEPTIC �4�vt �� <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) `,- — _ L .—bR <br /> j / - <br /> 4 AfAREA TO NEAREST SQUARE FOOT: p 5 r �:- <br /> (Outside dimensions including unfinished area,attach yd garages and above grade decks or porches)` : � 1 ah � A <br /> BASEMENT: 1ST FLOOR: (q4 '' ® � � � <br /> - tt <br /> r ` ..s-r�941 A kk. 4, TOTAL SQUARE FOOTAGE: 4, ,, Y h ` <br /> 2ND FLOOR: FLOOR: -r <br /> i 16 Kr,� EPVIt kliS <br /> ESTIMATED CONSTRUCTION COST: �' � -,� �� <br /> ♦ ♦ ♦ ♦ ♦ ♦ Pa m ees«,1 <br /> (Please round to nearest dollar) ����� . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes igiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,iYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes tilNo <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 .iNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes WI No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —► -+ <br /> 545-112(4/08) <br />