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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER.INFORMATION„ z,% :, .,4�' . 0,3 , ,.._ :- , fs - '. CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Ti>itaS d ka4�e.. --21cl ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) ,, / Deed Restriction;CSM
<br /> 'floc, �?i L2�, / of<3 (, 1537/( Variance(# )
<br /> HOME PHONE /} CELL PHONE E-MAIL ADDRESS
<br /> - 9 ` "� 7 ,-( 74 1 R . ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION. . . CONTRACTOR INFORMATION ' and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> MatC c c5 d&-ics eo 'TO/t Z
<br /> i 5(c ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,Stts,Zip.) ❑ Setbacks
<br /> Ft 1- 404/doe? 145 3 71(
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> LL
<br /> 110V— (01%5-- 74i 97 V-"- 73/V7 applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> LI Floor plans to scale -
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wims/) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rtY
<br /> LI PARCEL ,�tp/U-l6 areg7_? _ t` I L y 1 1 ( i frontage drawn to scale.
<br /> NUMBER y
<br /> TOWNSHIP: SECTION:
<br /> 17j,Lac,i & ,/: NU) 1/1/: I/U) ❑ Driveway permits
<br /> (state,county,town
<br /> ADDRESS: �p /� �j!i ( ry� )
<br /> i4 7E ` '` & I ,,'� '5 n C $ ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION � B+,G OI d1- Gj 4 s' 'V14 (public,private)•
<br /> PROPOSED PROJECT INFORMATION TA ,
<br /> �PROJECT DESCRIPTION: ' O X-RO //�h 4, - :, !
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<br /> ( " tod '-- am'
<br /> This project is a new building or structure. 04/ p 07 it'h ,.glti- - ` 3�
<br /> VI This project is an addition/alteration to an existing building or structure. ± _ ,.
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<br /> SANITARY SERVICE: PERMIT NUMBER: ; �g¢" °°; , � s
<br /> *EWER ❑SEPTIC `rr '"` L -
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) . c ��. ..�
<br /> ?I eta ;∎iiri�� t 4 ice, ,,
<br /> AREA TO NEAREST SQUARE FOOT: ��
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) f �"5 1 '� ,
<br /> BASEMENT: 15 L�O'�OR: {'r.. a ° �
<br /> (�I ( t�� is -7(2)8 G TOTpL SQUARE F OTAGE: i t at &!....,Ea
<br /> 2ND FLOOR: 3RD FLOOR: @
<br /> ate"„� . , ,
<br /> a ,
<br /> e m a r"°'
<br /> ESTIMATED CONSTRUCTION COST: --► ♦ -► -► -i -► $
<br /> Q � a® � �(Please round to nearest dollar)
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ErNo ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes j,No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? EYes 0� No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes xxNo
<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 ❑No ❑Don't know 0.
<br /> 7. Is this to correct a violation? ❑Yes „No J
<br /> -f( rk
<br /> ' Q) () APPLICATION MUST BE SIGNEDc�—sas1t21aioe) ���) � � (Continue on Back) -� ♦� CF a
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