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<br /> • d(-, 2fLL o� [14/02)
<br /> ZONING PERMIT APPLICATION www.couniyofdane.com SUPPLEMENT to Web•App#
<br /> PROPERTY OWNER INFORMATION'a� _ '4,. � u� ,�, �.::. t
<br /> �- , -�•~� •' { , -� CUSTOMER TO PROVIDE
<br /> OWNER NAME +
<br /> Jam r `.- s,it" ��r `�(� , Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,itty,State,Zip)nn `, r // eed Restriction;CSM
<br /> /0 7 s hesh e.W . i'(C� �cC�a(a w� � 3� Variance(# )
<br /> HOME PHONE! ` CELL PHONE E-MAIL ADDRESS
<br /> U 7v�I 0. Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR:INF.ORMATION' ' :-` - d includes dimensions
<br /> AtNT NAME C. CONTRACTOR NAME
<br /> r-oJ\ „G►�(/ fihov _ 5- ,A CJS•t /r-'4- 04� li' t ' '
<br /> ite Plan including location
<br /> AGENT ADDRESS CONyRACT RADDRE OTWell/septic iTcir(ray 57'. __,
<br /> (City,State,4p)f j w I `r (City,State,Ziy f f �� -„,7! G Setbacks
<br /> `t °1(5' -J- 55' 1 Gt4to` s S
<br /> PHONE q PHONE Ite Plan approval from
<br /> .L d ( '2367 7O$ ,Zo Y ,z5r7 applicable township:
<br /> E-MAILADDRESS E-MAIL ADDRESS �,7
<br /> OaIt`CA f s,t01 ,er,�I .Ce't/� co vi l`l Flo plans to scale
<br /> PROPERTY/LOCATION INFORMATIOiiI +.;(http:1/accessdane.co.dane.wi.usn,' Elevation of property
<br /> PARENT PARC L MBER: C E TZONING: ACREAGE: P P y
<br /> ❑ PARCEL az /]`2-�Y 5 , f frontage drawn to scale.
<br /> NUMBER l 'L7.7 l (`
<br /> TOWNSHIP: / SECTION:
<br /> 0 r7 • D r4-”r of .1/4: ,/,/: riveway permits
<br /> ADDRESS: , (state,county,town)
<br /> 107.x' fUeS 4e, Rd AFCr,- ;((d c.- 5355/ .
<br /> CSM: LOT SUBDIVISION BLOCK/LOT t�/�' - I -rY private)
<br /> permits
<br /> '61 blic,private)
<br /> PROPOSED PROJECT INFORMATION, j -_ —"` 4.
<br /> PRO ECTD SCRIjP�TION: � ��•
<br /> UPC 1 CA /Qvt Stiff J,t � *,RP ,-4 z
<br /> ❑This project is a new building or structure. . .
<br /> .(4F This project is an addition/alteration to an existing building or structure. T r
<br /> SANITARY SERVICE: PERMIT NUMBER: P ft -
<br /> ❑SEWER SEPTIC z t , vattt∎Di ''' f c:
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) ° ,` � ate.
<br /> 1 l � Wl? B fi
<br /> AREA TO NEAREST SQUARE FOOT: �� �
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches x �° 1b ,,, � `��'
<br /> BASEMENT: 1ST FLOOR: Y----,-- q�� �. r
<br /> ,Z� 4, TOTAL SQUARE FOOTAGE: 1 a 'a m- - '
<br /> 2ND FLOOR: 3RD FLOOR: O `
<br /> ESTIMATED CONSTRUCTION COST: _1,, _4,, • ' _1, oce r t 3
<br /> (Please round to nearest dollar) � t
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes lI No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IErNo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes $lNo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes gj 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) KYes ❑No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes PKtNo
<br /> AIAIUST B—E E
<br /> (Continue PPL CT on ON BacMk) ►SIGN—► —'D
<br /> 545-112(4/08)
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