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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#: <br /> PROPERTY OWNER;INFORMATION:',-;',,s, z?,' '.'.'N0``30V.e-,ri,,' -:.:-=,'L-, z, .r :: CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> • <br /> 4 ,41 Y S, SoRWtr 6 C-R -LL <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 11 `1, Cod y h/. ,.C—o a � r Al ) !v i 6 3 5�'9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> D �3 --i--3/1-1 576 -ir-6 A 3 LI Site Plan drawn to scale <br /> AGENT INFORMATION - CONTRACTOR;:INFORMATION x and includes dimensions <br /> AGENTC,NAME CONTRACTOR NAME <br /> 'S ,iii - LI Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE • ❑ Site Plan approval from <br /> applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION:INFORMATION +::(http://accessdane.co.danewLusn ❑ Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> P rty <br /> ❑ PARC frontage drawn to scale. <br /> NUMB EL 0/ER 6/v6/2-3�1-90 -0 <br /> TOWNSHIP: SECTION: <br /> a.` R� <br /> 2/S T-��� //.3c. 1/4 44 ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 9/996 4x114. ' Olri5/v(J 4 j o / / '-B o cULOT ❑ Sanitary permits <br /> CSM: SUBDIVISION <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION, "': � T47, <br /> PROJECT DESCRIPTION: x ; <br /> o f1I Hie S-A'4 c/ 'Il m s' <br /> LI This project is a new building or structure. <br /> Cr This project is an addition/alteration to an existing building or structure. _ ,• <br /> SANITARY SERVICE: PERMIT NUMBER: °t'q • <br /> ❑SEWER ❑SEPTIC � `Or*O <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) s. `„ ' <br /> I e 48 , g <br /> BASEMENT: 1ST FLOOR: 'sk <br /> GE: J, ��4 a <br /> Yci.x- <br /> )� 4, TOTAL SQUARE E FOOTAGE Tx <br /> 2ND FLOOR: 3RD FLOOR: a ° 0 <br /> . ,_ Ls i° arc,, "s . <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) - -+ 3 Z'� 1 D U!� � � i ae <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ❑No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ©No LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ['Yes allo )ottilf I2,n 4 <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 2No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IA No <br /> 3-9 0,O0 APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -4 -4. <br /> 545-112(4/08) <br />