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','SUP•PLEMENT#01Ne6 Apps;:
<br /> ZONING PERMIT APPLICATION www.countyofdane.com
<br /> 'pROPERTYnQWNER INFORMATION WO?- ._.,. ,:'r A = CUSTOMER TO PROVIDE
<br /> OWNER NAME{
<br /> ' /% 77 G'/ /e
<br /> / ' n Zoning Status; CUP;
<br /> i OWNERADDRE (Numb et ity,s 2 - Deed Restriction; CSM
<br /> PH � /n ?( r
<br /> 47 .ge. � Variance(# )
<br /> HO PHONE CELL PHONE E-MAIL E ADDRESS
<br /> l z d:t%?�•" �— n Site Plan drawn to scale
<br /> •AGEN T_INFORMATION a,= _'.-_.'CONTRAC OltINFORMAT,ION z+`. . and includes dimensions
<br /> 'AG ME CONTR.CNOR NAME _1
<br /> ,-./.4,2 Ze . / C/Cc,, ,�,a� ( ' 0 Site Plan including location
<br /> AGENNTAADDRESSS CO/NTRRACTO DRESS x S of well/septic
<br /> (City,Sta p)
<br /> (City,State,iiP) El Setbacks
<br /> 5J%,,,,, Z- Z./// 9 V 1 ,2C?, 2-0 T —f )�
<br /> PHONE PHONE O Site Plan approval from
<br /> . 6 a - ,) -.0 J,75-- �d�_ r&-- 9766 applicable township.
<br /> E-MA LADDRESS 49 / E-M LADDRES®S •
<br /> ❑Floor plans to scale C l ec� "4.,..,,..a....40 4021../ ZEa / C/Cow, 4 ,fcl ,!v/
<br /> PROPERTY/LOCATION INFORMATION ;(http//eccessdane eo:dane i usl) r't
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE Elevation of property
<br /> ['PARCEL _. frontage drawn to scale.
<br /> NUMBER
<br /> TOWNSHIP: SECTION:
<br /> '/4: %'/a: ['Driveway permits
<br /> •
<br /> ADDRESS: J (state,county,town)
<br /> O Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION _ 4 `-x`S,TiAFF REVIEW ' ,
<br /> PROJECT DESCRIPTION: /, p ; }p5. t� -€
<br /> �.�r'��x/�� e-° �� �65-� 1��� r•� onidrilignct= 'K & ``i `
<br /> . his project is a new building or structure. L PeCmltf lrUse? fA, r ;x
<br /> ❑This project is an addition/alteration to an existing building or structure. - r<`"'` f; r
<br /> SANITARY SERVICE ; s }`r?
<br /> '°�=RurahAddress:
<br /> PERMIT NUMBER ��,"i�'w-'
<br /> rrnewlexlstin : v''-''t:
<br /> rEwER [EPTIC _..1,:<° ,. 9�=: ::;r;
<br /> HEIGHT IN FEET� ;�it NUMBER OF STORIES: (Not including basement) � ,�,, �;� �' � y
<br /> /L ® We`t and/Floodpia /, �...
<br /> ` , ofelandy(attaclhment):�
<br /> AREA TO NEAREST SQUARE FOOT A'.-''Q* =='"•= "412:6,=``'"
<br /> Via:Vii-.' L `0i:'1i'-,,'r 'r-1.��'_,.i�'ti:"t;=At
<br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) --.,..7( =Y=y-; =4,,,—,-fir-"<<,
<br /> BASEMENT: 1ST OOR: °® EfO A^OnCOntrAi t ft
<br /> �' G q TOTAL SQUARE FOOTAGE: SIOpeS,ostur�a:nce
<br /> 3RD FLOOR � 1>-f IIU1���7CC ss YK>� r;:sY�::�_.r
<br /> 2ND FLOOR 3 -.4--:44'9 "./.
<br /> �� MoD�� _ -. 4, -..., .
<br /> w L tIOri SUrvely
<br /> ESTIMATED CONSTRUCTION COST: .., i, `°"a!opt
<br /> ( ) ♦ ♦ ♦ -4 -4 -� .''t �an'd,_ke-W,'tiie�oitlo-
<br /> Please round to nearest dollar) 0:b •T, `- '` r, r'%s "``4-ri
<br /> '-i`�}�:r'aa?.w.�'i�..:;�m!rµ,'.-'c_•;-fi�_a_t- _yri.
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dyes Flo ODon't know
<br /> 2. Is there a wetland or floodplain on or near the property? 01'es to QDon't know
<br /> 3. Have you talked with the township about your project and are they in agreement? R‘s ONo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - ['Yes to
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if one)
<br /> 6. Is a location survey required? (see reverse) Dyes Flo ODon't know
<br /> 7. Is this to correct a violation?- OYes Flo
<br /> /Jtp APPLICATION MUST BE SIGNED
<br /> (Continue on Back) -i -► .4
<br /> 545-112(4108) .
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