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J- 3 I.). <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION„ r;',.. . -.?: n,43 L h 'i, CUSTOMER TO PROVIDE <br /> OWNER E fl /I iv ► <br /> OWNER ADDRESS (Number,Street,Ci ,State,Zip) je Zoning Status;CUP; <br /> le es R I Deed Restriction;CSM <br /> a.T c- tit no( Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60 V 8`/'-fat/ ' ! Site drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION.. . - • Inc des dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 1)lRfc°1T /Jta P vil C0,4STivcc, I Site Plan including location <br /> AGENT ADDRESS _ CONTRACTOR ADDRESS of well/septic <br /> S e 4 ( vl r ve,- RA- <br /> ( ity,state,Zip) (City,State,Zip) Setbacks <br /> L v a vvl R kc5 1--, 3-3 f91 <br /> PHONE PHONE Si Sit I pproval from <br /> 60Y '2- 19 57?0 a ' ble township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 'It d/% /7t,,,nw-f d 6r-,,r%4.-n. 9\Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.usnlevation of <br /> PARENT PARCEL NU, BER: CURRENT ZONING: / ro e <br /> � p p rty <br /> ❑ NUMBER 06 )- !bag 9yi-f° V eN- Z rontag edrawntoscale. <br /> TOWNSHIP: SECTION: <br /> Vtld✓I 3 y 1/4: Ni %1/: ��- ! (state ty, o <br /> (state o ty,town) <br /> ADDRESSf:Q Q <br /> `" �� q ��' <br /> pm' Sanitalgtrmits <br /> v <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub ti<, ate) <br /> 1 L4 <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: /� L , t <br /> Gar-a i ,4A4;I•� 0 Q)(C� ,.. a <br /> ❑This project is a new building or structure. - <br /> 3 This project is an addition/alteration to an existing building or structure. ; i V <br /> SANITARY SERVICE: PERMIT NUM R L '1::11 "° �°�s�IP : � <br /> ❑SEWER RI SEPTIC °��� I �'' <br /> ,, � $:. - <br /> HEIGHT IN FEET 41 NUMBER OF S OR S: (Not including basement) �' t s <br /> AREA TO NEAREST SQUARE FOOT: ' err !? ,.. t'� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: � - �'� � , <br /> /� � 4 TOTAL SQUARE FOOTAGE: ,l, �� � ��, a��-s �� ����� �'� <br /> -:11.051;e1 �. <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: /1 I/ T Q i ,t ®�c e : it <br /> (Please round to nearest dollar) -∎ ♦ -► -► ♦ -► $ 7 is" <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes [N No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes '0 No CI 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 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) CI Yes allo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes &No <br /> AIAIUSE ID <br /> 545-112(4i0s) (ContPPLi Cnue T on ON BacMk)T B_i S-�GNE-► <br />