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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#: <br /> PROPERTY,OWNER INFORMATION„�;,-;;;;'.::...7.:_ '1:' 1 `;` °?,�� - , .=..,.'.< ,'?;,*- �' CUSTOMER TO PR E <br /> OWNER NAME j f <br /> J a v-5 40 Loa✓'ek • ❑ Zoning Sta ;CUP; <br /> OWNER ADDRESS (Number,Stree City,State,Zip) � t- Deed R riction;CSM <br /> 6 Eck? Vet 1 g( 3(60 k)-1 et idJ— .�3 s I ari ce(# ) <br /> HOME PHONE CELL P NE E-MAIL A6DRESS <br /> 60';-5/62% (o 4 avers 11)-c i.k)_Vc• 1.€4.- Sit Plan drawn to scale <br /> AGENT INFORMATION - COhTRACTOR:JNF.ORMATION ;:;- a d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> S' Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE • ❑ Si Plan proval from <br /> pli a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusl)usn;; Elevation of property <br /> PARENT PPARR�CE NU BEER: a„a5/09,... CURRE T)Z/ONING: ACREAGE: p p rty <br /> ❑ NUMBER �J © �”` ! ` /, 3 frontage drawn ale. <br /> TOWNSHIP: S CT+g� ❑ Drive <br /> ©ieGodo ( 1/<: N W 1/1/: Dr , a permits • <br /> ADDRESS: <br /> ELA.Val - /, • <br /> ❑ Sanitary rmits <br /> csM: I>• % SUBDIVISION BLOCK/LOT (pub' ,private) <br /> Ore on �?ss, ro. rown r� <br /> PROPOSED PROJECT INFORMATION '"-r , <br /> PROJECT DESCRIPTION: ' ° 'i a- A .x . <br /> This project is a new building or structure. a � :, <br /> ❑This project is an addition/- eration to an existing building or structure. ti, s <br /> � ,. <br /> SANITARY SERVICE: PERMIT NUMBER: `g�9 1a ,��" ' , � <br /> EWER 7 SEPTIC -10, -; <br /> s <br /> HEIGHT IN FE © NUMBER OF'STORIES. (Not including basement) "' • r —. s <br /> iL � -1 <br /> AREA TO NEAREST SQUARE FOOT: 1`; ' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,_ � i ,1. <br /> BASEMENT: 1ST FLOOR: r�®� s��1 , r$� <br /> V x OZ7 • 4, TOTAL SQUARE FOOTAGE: 4, ;�' a Y. ,. <br /> " <br /> 2ND FLOOR: 3RD FLOOR: e °a � �� j•ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ -► 0 6 . " i , Iti <br /> (Please round to nearest dollar) $ c2 0 O C, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,iI No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑YesN ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes '•;! o <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 ,r No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes u�tNo <br /> 4 ?9, r--- <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —. —► <br /> 545-112(4/08) <br />