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ZONING PERMIT APPLICATION wcountyofdane.com SUPPLEMENT to #
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<br /> PROPERTY OWNER;.INFORMATION°i.-.4 , ' + u ; : -. r:
<br /> OWNER NAME 0 CUSTOMER TO PROVIDE
<br /> Or/41.4 l ./ - Q"--
<br /> OWNER ADDRESS,(Numbe��r,//J��tr t, ity,St e,Zip D ,/J ❑ Zoning Status;CUP;
<br /> Sys/ /�/i 4 Airs.2on,a,,;e 1,v1 S,3S6 o Deed Restriction;CSM
<br /> Variance(# )
<br /> HOME PHONE CELL PHONE
<br /> E-MAIL ADDRESS
<br /> Co 0 k 76 7 y3 0 3 (DO g 661-g6 y3 , Oeh•, ,,Q tiG ,---) ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION,-. CONTRACTOR:INFORMATION. and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> AGENT ADDRESS ❑ Site Plan including location
<br /> CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION :(http://accessdane.codane.wi.usn
<br /> PARENT PARCEL NUMBER: CURB TZONING: ACREAGE: ❑ Elevation of property
<br /> ® PARCEL
<br /> NUMBER U D(,--)-0-453/-0 / /,4 3�� ,, frontage drawn to scale.
<br /> TOWNSHIP: // ��JJ � SECTION:
<br /> !4 c� �//a�0//� 1/C -/1/: LI Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> SY y iili;a Li) 4 /14a-L-6,t,,.A,e w r 5-3S4. 0
<br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION '�
<br /> p }PROJECT DESCRIPTION: ,s,..,/�
<br /> • This project is a new building or structure. •,� � , ,-4 _` �`"
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<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: —
<br /> PERMIT NUMBER: 44r 11 e a =,v
<br /> D SEWER ❑SEPTIC
<br /> � � R av
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<br /> �� ' -HEIGHT IN FEET , • NUMBER OF STORIES: (Not including basement)
<br /> 12
<br /> . r eij - =':
<br /> AREA TO NEAREST SQUARE FOOT: ® `
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r
<br /> BASEMENT: 1ST FLOOR: T,J e p
<br /> /2-R V 4, TOTAL SQUARE FOOTAGE: 4, s .s m r
<br /> 2ND FLOOR: 3RD FLOOR: ) � ° ,.,� ,
<br /> /c2F-U 6'I LN n '
<br /> ESTIMATED CONSTRUCTION COST 71# s c �i -
<br /> (Please round to nearest dollar) —∎ '∎ —∎ ♦ --► —► $ 1 S >. -. 1,0;�
<br /> 3 z `1c Lit,'
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ... N o ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 'No ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? „Q'Yes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes .21No
<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 ,,dfNo ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes LiNo
<br /> APPLICATION MUST BE SIGNED
<br /> 545-112(4/08) (Continue on Back) —0. -0. -0
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