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Z <br /> 058 o '?.---Th- <br /> ZONING PERMIT APPLICATION ww .countyofdane.com SUPPLEMENT to Web-App# <br /> w <br /> PROPERTY OWNER INFORMATION`, i 1. �.V 4',- _ ..x._: `t ;: 1' <br /> OWNER NAME <br /> - • � �° CUSTOMER TO PROVIDE <br /> Ea uocurd 6 r ftun A \,n ❑ Zoning Status;CUP; <br /> OWNED DRESS..(Number,Stree,City,State,Zi ) Deed Restriction CSM <br /> l a`` • s - 1 I RA i n Bert W Variance(# ) <br /> H ^E HONE 2 CELL PHONE <br /> ) E-MAIL ADDRESS <br /> U�lD"" 561"> 51 L,—,55-13 1Site Plan drawn to scale t,l I '( <br /> AGENT INFORMATION CONTRACTOR:INFORMATION.; ' , -i and <br /> includes dimensions <br /> AGENT NAME CO RC NALMva1; "e • ' 4 •1%leiniuding <br /> location <br /> AGENT ADDRESS CONTRACTO DRESS of well/septic <br /> (City,State,Zip) ( iry,State,z ( i Yv 1 4 ❑ Setbacks <br /> PHONE ql lopes ❑ Site Plan approval from <br /> WC— 3a"?•14-1 1 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El Floor plans to scale <br /> PROPERTY/LOCATION;INFORMATION;':;(http:llaccessdane.co danewi.usl): C! Elevation of property <br /> PARENT PARCEL UMBER: CUR ENTZONIN ACREA P P rty <br /> ❑ PARCEL (MA o tO-v' 1.. t 1-� a L� frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SEGT w` <br /> , V S Indso IC I 1/: N 1/41/: ,V ❑ Driveway permits j`\(A, <br /> (state,county,town) <br /> ADDRESS: ` '_ 1 <br /> 1 I a 4 S . C4'I 1 l Rd ❑ permits <br /> CSM: LOT -A t Bgly,sloN BLOCK/LOT <br /> (public, .rivate) <br /> PROPOSED PROJECT INFORMATION. - ' 1 T <br /> PROJECT DESCRIPTION: 1 <br /> Sc r rtroofl1 �. DU_ K �? 4I0 -, <br /> • ❑This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. = ' <br /> SANITARY SERVICE: PERMIT NUMBER: 1`1=.`°r' n- '" — <br /> ASEWER ❑SEPTIC i�L , ' <br /> HEIGHT IN FEET: - NUMBER OF STORIES: (Not including basement) ' " <br /> R° ;1s ": <br /> AREA TO NEAREST SQUARE FOOT: " <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ; . <br /> BASEMENT: 1ST FLOOR: m �� e '1't�`�2 , <br /> 4Y 13- Z 1 _ 4 TOTAL SQUARE FOOTAGE: n �� s€ ° <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2 3 i'.1 `c s ' <br /> i fFes" II a3*° 9 W➢ "S6,,,r ;;# <br /> ESTIMATED CONSTRUCTION COST: l ' ���� : <br /> Please round to nearest dollar $ 1 450.00 ea,t '` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? XiYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No N 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 perniitigsued for this property in ttre•past 5 years? .. LI Yes !lo <br /> 5. Is this project associated With a rezone/CUP/variance(petition/appeal# ) (eve bl nk 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' ictglo •, ' <br /> i(o <br /> 50 APPLICATION MUST BE SIGNED <br /> 545-112(4109) 1/ i�b,.o <br /> 0 (Continue on Back) .-■ -► -. <br />