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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to Web•App#•
<br /> PROPERTY-OWNER;:INFORMATION
<br /> ; ?4 ' : 0 <t-J1,
<br /> ° CUSTOMER TO PROVIDE OWNER NAME
<br /> .0;3 M‘c G e' 9c,4
<br /> ❑ Zonin g Stat P
<br /> OWNER ADDRESS (Number,Street,City,State,Zip') D ed riction;CSM
<br /> --79a. Ht.v q 115' L0 u3T S�SSS ar nce(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS -
<br /> (008 S9 V Sao te 4:08 a N 13,;b - . c.- e.,-1-+',-...._)@ -,-Si--,rco,,,cc, Site Plan drawn to scale
<br /> AGENT INFORMATION i CONTRACTOR:INFORMATION`:: rj d includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> l op C-0A-S-- ;,c,.) .-;,w` Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS 7 well/septic
<br /> •
<br /> (City,State,Zip) (City,State,Zip) a Setbacks
<br /> 1 1' 5
<br /> Wa.u,wr-.,k:ee WI SJS`( 7
<br /> PHONE PHONE • ) ❑ Site Plan a al from
<br /> pplic a township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> F or plans to scale
<br /> PROPERTY/LOCATION:INFORMATION (http://accessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property
<br /> ❑ PARCEL �/ G� 9 a frontage drawn to scale.
<br /> NUMBER CY°lo1'O`ta$-03�'Sa`IO 3 '�' � `� 1-
<br /> TOWNSHIP: SECTION:
<br /> e__ b3 ,/: IJ L %%: ❑ Drivew ermits
<br /> ADDRESS: (St ,county,town)
<br /> 79.3,1 Nay Ha Lam, , 0= s,SS ❑ Sanitary mits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (publi , rivate)
<br /> PROPOSED PROJECT INFORMATION.:!:;
<br /> PROJECT DESCRIPT N: �N �I I:; ' :;:�A ,. .- Q -
<br /> . :` ; ri d
<br /> ❑This project is a new building or structure.
<br /> � -
<br /> .549This project is an addition/alteration to an existing building or structure. • . ff
<br /> SANITARY SERVICE: ,' ems/` 9.. ' , ''„
<br /> PERMIT NUMBER: ��'��°,� ..��„.� �
<br /> ,
<br /> ❑SEWER SEPTIC 7, :-`7 `,
<br /> HEIGHT IN FEET: /
<br /> NUMBER OF STORIES: (Not including basement) : 'e- '
<br /> AREA TO NEAREST SQUARE FOOT: ki*--
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �� � / (�
<br /> .('N
<br /> e ® °9Rfl��P� Y" UJ
<br /> BASEMENT: 1ST FLOOR: (�
<br /> �� �c I I j TOTAL SQUARE FOOTAGE: , e ;�I p t7 Q r
<br /> v3,j i S "� 1
<br /> 2ND FLOOR: 3RD FLOOR: /
<br /> (/ / , ,
<br /> 8 "ey- : .�° E Cif
<br /> ESTIMATED CONSTRUCTION COST: ♦ .4. .... ♦ .4. .4. r , rnrn , �� �t g 9i�
<br /> (Please round to nearest dollar) 5 V ,i.. _ ^ 1-771'_ ;
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes * No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes V.No ❑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 permit issued for this property in the past 5 years? ❑Yes WNo
<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 14 No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes No
<br /> / 3 ? , APPLICATION MUST BE SIGNED
<br /> Continue on Back) - -►
<br /> 545-112(4/08) ( -0. -►
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