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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# •
<br /> PROPERTY OWNER;INFORM•TION , '? ' t f ' ' CUSTOMER TO PROVIDE
<br /> OWNER NAME '
<br /> GO e f, 1� rZ 7' t&LLE 1Z oning Status;CUP;
<br /> OWNER AD R S (Number,Street,City, te,Zip)
<br /> 1?020 a_EO 14/4 N, �1V ed Restriction;CSM
<br /> HOME PHONE CELL PHONE I Variance(# )
<br /> E-MAIL ADDRESS
<br /> . 73- 70' Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions
<br /> AGENT NAME C CONTRACTOR NAME
<br /> fa'}- e_CE)/ 951 , -iu bat-3A L T1Z i Plan including location
<br /> AGENT ADDRESS E g
<br /> CONTRACTOR ADDRESS of well/septic
<br /> a3,&3 v4 ILL ttt,t,.s -Z3,..?3 1/x-1)LL IAAA 5 1-) .-
<br /> (City,State,Zip) (City,State,Zip) A,.J Setbacks
<br /> 5 O L i-C Tot...);)(Li 1.S-6,5 59 `-i-0 u c,i4;Ot t t t _S3S sil t4i,„---
<br /> PHONE PHONE 0 Site Plan approval from
<br /> 406-- &73-35 Of tp o k- 873- 3So r) appl•cable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> bC-Sot 30 4+It O ,(--e))4-x b -• .2, L3 ) el Ho O , (v loor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: II - evation of property
<br /> 0 PARCEL
<br /> NUMBER ,/'rontage drawn to scale.
<br /> TOWNSHIP: SECTION:
<br /> +/,: ,/,/: Or ewaypermits
<br /> ADDRESS: (state,county,town)OLA
<br /> CSM: LOT SUBDIVISION BLOCK/LOT nitary permits
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION 4 E
<br /> PROJECT DESCRIPTION: '-'1 R
<br /> R-e5 LA ZPA C-E b'E c-e- i R5 L-ocriew-z.-.. s 7-e-_--p s ,-,-,...,:;:nifral.vp,AV,-!sj;,A, - ' ' 7.,;:-
<br /> • ❑This project is a new building or structure. p
<br /> Et-This project is an addition/alteration to an existing building or structure. °° ;4 ,- :
<br /> SANITARYSERV E: PERMIT NUMBER: '. e4 gi,beta€I`"�. �
<br /> Ai; EWER ❑SEPTIC ' a a;n -
<br /> HEIGHT IN ET:e , r NUMBER OF STORIES: (Not including basement)
<br /> AREA TO NEAREST SQUARE FOOT:--•'`t,:-_„ , �� ��
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �i ��.# ;
<br /> BASEMENT: 1ST FLOOR: _ �� 56
<br /> 32.7,1 T ,, TOTAL SQUARE FOOTAGE: ,, "�-1 r( � '16 m o- 4'
<br /> 2ND FLOOR: 3RD FLOOR: `0 I °� �4
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ pr rig v t d�° t
<br /> (Please round to nearest dollar) $ f 2l 0 CO- — ,. �, ,
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake?
<br /> liik$er- lo ❑Don't know
<br /> 2. Is there ayetlnd or floodplain on or near the property? ❑Yes lo RIDon't know
<br /> 3. Have y talke with the township about your project and are they in agreement'? ❑Yes ,®No(`ii WE NOTImo- t-Ri74
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes Otto 2-ir7 1 q q 3131 5
<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) in es ❑No ❑Don't know
<br /> 7. Is this to correct a violation? M'es ❑No
<br /> APPLICATION MUST BE SIGNED
<br /> 545-112(4/08) (Continue on Back) -0. - -+
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