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ZONING PERMIT APPLICATION www.countyofdane.com .SUPPLEMENT-toWeb-App# <br /> PROPERTY OWNER::INFORMATION ti�; - _, _;- .. 1-3-,. _,.-i. !, <br /> CUSTOMER TO PROVIDE N E atcki <br /> WNER ADDRESS (Numb r,Street,City,State,Zip) - Zoning Status;CUP; <br /> V2 Cs3 COc. u. 1 ("0-4--t- F-i 1--C.a u✓ (4)1_ .53 71/ Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRE <br /> 6.&- (- 2,--Ili 1,(3. --.3 N 7 5-s3 3 A 10 Site Plan drawn to scale <br /> AGENT INFORMATION:-. CONTRACTOR INFORMATION iY - and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> SC of- CiP/1'4•0 ■ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR AD RESS r of well/septic <br /> -g6-C- 1 CtCL ifel.A.Q <br /> j(eity,State,Zip) (City,S te, ip) Setbacks <br /> Pt w? 53 7 I/ <br /> PHONE PHONE • ASite Plan approval from <br /> 60 e-31�7-.3 S,S' applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> N 11 AFloor plans to scale <br /> PROPERTY/LOCATION'INFORMATION (http:l/accessdane.co.danewi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> PARCEL <br /> NUMBER D Co l 6-253-t2oo- y R_3 frontage drawn to scale. <br /> TOWNSHI SECTION: <br /> v Y\1,.- 2SJ SW +A: op A)E +/1/; 'Driveway permits <br /> ADORES : (state,county,town) <br /> 337°133- Z 4 LA 414■ D I V k 5i-0,4,k,-, WT 53 s� q I• Sanitary permits <br /> CSM: LOT DIVISION_ BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTIq�� ,-'' .s °- a `7`=z <br /> I l to �o+ , ecic- d� fi ��' 3- <br /> ❑This project is a new building or structure. Q <br /> p This project is an additio alteratio • an existing building or structure. a <br /> SANITARY SERVICE: '''Zilr�t� e RI sue= ''�' <br /> PERMIT NUMB R: R �y <br /> ■ SEWER ❑SEPTIC . fi.',t� - <br /> HEIGHT IN FEET t NUMBER OF STORIES: (Not including basement) s t <br /> AREA TO NEAREST SQUARE FOOT: � � r`` � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ` -- � <br /> BASEMENT: 1ST FLOOR: <br /> . ®a O ®"Y <br /> A) TOTAL SQUARE FOOTAGE: - i e „ , <br /> 2ND FLOOR: r�' �.� t ; <br /> 3RD FLOOR: t -- <br /> A-r S/t <br /> ESTIMATED CONSTRUCTION COST: ? �� a, <br /> (Please round to nearest dollar) $ / L.V.O (J �: , r �r •A <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 51No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ' No ❑Don't know <br /> NA-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 LvNo <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 it No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 410 <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/0B) (Continue on Back) -► -4* <br />