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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION'-...':,' n =''1
<br /> --x �-.0•^~ ;.�.,. '' :,.:::::.t CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Ne r
<br /> c,,-c/ RA oning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State, ip) ]]
<br /> )
<br /> Peed 3 cS C, 1`'N 1—c i f ei I' o Y ;1., .. ( 1 aria Restriction;CSM
<br /> Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> 4► 4 —6-'43— -. 1 .- - Ir Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> I°O ')\ E 11 r'\ate-\ Lii, ite Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic
<br /> Q I / 61-13 ri rn 6 0,-,6-.0 .
<br /> (City,State, ip) (City,State,Zip) I♦ Setbacks
<br /> C ) u r,),,,,, 5.�
<br /> s A--`,_% c1 a c
<br /> /PHONE PHONE ill -ite Plan approval from
<br /> GOB—G--3— . -j ! applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> -door plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danewi.us/) ►_ Elevation of property
<br /> PARENT PARCEL NUMBER: CUR NTZOTIING: ACREAGE: P P rty
<br /> 0 PARCEL �^ — I 1 I � rontage drawn to scale.
<br /> NUMBER C a6II-) 3 1�1�'� t"7
<br /> TOW,SHIP: SECTION:
<br /> (Jv , ,A. j-Y") 1/1/: c-V\J 1 riveway permits
<br /> ADDRESS: (state,county,town)
<br /> 5 3 C�Ar ' Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> public,private)
<br /> PROPOSED PROJECT INFORMATION;
<br /> PROJECT DESCRIPTION: T "ate r -
<br /> • ❑This project is a new building or structure. I,„1. 1 -.
<br /> .This project is an addition/alteration to an existing building or structure. � , i f,
<br /> SANITARY SERVICE: PERMIT NUM-E-• ��` -1 l.s'� ' z r
<br /> ❑SEWER 2 EPTIC di ' nl"'4_ p "
<br /> HEIGHT IN FEET: NUMBER•• S OR ES: (Not including basement) � ..,,r„,.:..„:..,,.,., ,__. „ ,,,,
<br /> 7,'d : Ye ;,, �};, 6/ air _
<br /> #,,
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> rvir,,,,..„.4i:_. :,,,,..,..,;.:€,. .,,_,:.,_.,,(Outside dimensions including unfinished area attached garages and above grade decks or porches) ..,,,,.:.„„.
<br /> BASEMENT: 1ST FLOOR:
<br /> 4, TOTAL SQUARE FOOTAGE: ® +4 .,
<br /> V :
<br /> 2ND FLOOR: 3RD FLOOR: x
<br /> ,� 33�, i � � .S'h y a
<br /> . "
<br /> ESTIMATED CONSTRUCTION COST: r yw ® 1 � ,,-4. -+ -+ ♦ -► ♦ QQ )e___,(Please round to nearest dollar)
<br /> ti
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes-c io ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 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 --EINo
<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 --E(No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes ''t'to
<br /> APPLICATION MUST BE SIGNED
<br /> 545-112(4/08) (Continue on Back) —► —►
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