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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENTao Web�App#
<br /> PROPERTY OWNER i.INFORMATION ,,;: , z=_ '.45t!; w ,il1,;; : ,�._, < <,J1 CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> 'T€UE p°t,tD 'R°' ,` -BDc,Lia Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM
<br /> Iatr,.. -PIi.IE\ItEW -t\J / 6R.o1.. ,4, v,1■ 5s5-13 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> `B " 115 5 '64-1- 4(04 a iosAvl3 CI X.°I-.Co v..1‘ tSite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION:' : and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> jAM,(g. 0oRu3Dbu 6Ll5-cb1 \ ( -„M ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> Zf S S TgluEt<Tati1 1K-E _ „(
<br /> (City,State,Zip) (City,State,Zip) C._I Setbacks
<br /> hAA,D(Sod1 \n(c 5`31i(
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> 10.03— 274 '4--1 0 applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> 14ki1 ci Nit,0,,300. c_LtS 0tvtFtaM;4-Zo plans to scale
<br /> PROPERTY/LOCATION:INFORMATION ?;(http://accessdane.co.dane.wi.usl) ;; -' Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: oP P y
<br /> ❑ PARCEL _' f 14' ontage drawn to scale.
<br /> NUMBER F' (7
<br /> TOWNSHIP: .
<br /> _ /.2-PtttJV-DALE e'2 1A: i1E %I A: 6E Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> / `8 • 1'3 . 6. 'R i Ley ob Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> r g,1
<br /> PROPOSED PROJECT INFORMATION, ' *' T ,,•' PROJECT DESCRIPTION: 0, '`` a .., �;'-° �-
<br /> SteJC.,LS —F,, L _ _ ► � w'r
<br /> This project is a new building or structure. fir 5 �
<br /> ❑This project is an addition/alteration to an existing building or structure. R -4� , -
<br /> SANITARY SERVICE: PERMIT NUMBER: -
<br /> ❑SEWER •OtEPTIC 5 I i I I 4.1,, ,-z ,.
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) " s
<br /> AREA TO NEAREST SQUARE FOOT: 1-, 41 - --=
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches)
<br /> BASEMENT 1ST FLOOR: _ � Y � 'y
<br /> L�(O "z%��frT�1,'0�`t"i/5 4. TOTAL SQUARE FOOTAGE ,
<br /> 2ND FLOOR: 3RD FLOOR: � �1 a
<br /> — S 1 S a f..'4" YF ,:''' ,7:!..z,:-s,
<br /> ESTIMATED CONSTRUCTION COST: 00 ,, ' �'
<br /> ♦ —► --► --► —► Fr"m a ay e
<br /> (Please round to nearest dollar) $ 4--2- , 2300 " ' - -
<br /> -i1 L4'I5,c'r)
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ' 1 o ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? a'Yes ❑No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? ErYes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes allo
<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 CI Don't know
<br /> 7. Is this to correct a violation? ❑Yes allo
<br /> ICAUST BE EE
<br /> _o).
<br /> on TION BacMk) -►S.SIGNE 1 -i►
<br /> 545112(4/08)
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