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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME I�
<br /> r-1 I'chce/ /�t `/On 1..12oning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM
<br /> a5$ Bc ;Ie- y Rd. Sur, Prc ;rie_, W S 3S70 Va ' nce(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> Goi -8`3Y-0 '+ .1Wite Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> AGENT ADDRESS Vcar\lf 1 CONTRACTOR�DDRE/ �, h10/l oftye(Plan inccludinglocation
<br /> V? Sibf,eltorvc.,dr. AO • 5/ )5 8'3 6.,:ley Rd. .
<br /> (City,State,Zi ) (City,State,
<br /> Zip), Setbacks
<br /> S cal Prc«rie_ i /� 5 3 S0 S,,,,, Pro,,r,'e_ , e,./_r 5 3 Sy
<br /> 0
<br /> PHONE PHONE
<br /> ��
<br /> w"te Plan approval from
<br /> 60S- — IC/-7 —c,`t/. Q Cpg —(6'37—o Y5c applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> CV d,S$3C s •L,v°'co,n 4,Z plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property
<br /> PARENT PAR LJIUMB /2 _:TICURRENT NI G: ACREAGE: P p rty
<br /> ❑ PARCEL Q1 t �t��JJ tom, 5L� frontage drawn to scale.
<br /> NUMBER l ��ff" 1 ✓'
<br /> TOWNSHIP: SECTION: AR A/ /
<br /> S Prq,'ri /�0 '/<: /� w '/a'/a: /vW riveway permits
<br /> (state,county,town)
<br /> ADDRESS: n
<br /> g i 61' lc_ R d. Ste-, Prc'c-r e- W 5 35 It nitary permits
<br /> CSM: L 1
<br /> LOT SUBDIVISION BLOCK/LOT
<br /> oVo / (public,private)
<br /> �
<br /> PROPOSED PROJECT INFORMATION
<br /> PROJECT DESCRIPTION: -, ` ,, ' ""'s � a
<br /> . L7This project is a new building or structure. ' ;
<br /> ❑This project is an addition/alteration to an existing building or structure. -: fr .
<br /> � ����
<br /> SANITARY SERVICE: PERMIT NUMBER: - -m , • A
<br /> ❑SEWER jA - PTIC - '
<br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) _ � �
<br /> ® t,.
<br /> om rA 9t
<br /> AREA TO NEAREST SQUARE FOOT: T , .
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) s
<br /> BASEMENT: 1ST FLOOR: a ® :
<br /> 7 6 g j TOTAL SQUARE FOOTAGE: , ' 'I aYr'
<br /> 2ND FLOOR: 3RD FLOOR: ° . '• `
<br /> . 76 ' . ,� k !
<br /> ESTIMATED CONSTRUCTION COST: ,` , _ , °;, • 4
<br /> (Please round to nearest dollar) ■ --► • "4' "'■ $ 000 0:..i,
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? �❑Y allo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? I�Ae ' 0 No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? L�'YesLY- No r.
<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) ❑Yes IDN9,- ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes L' 'No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) —► —►
<br /> 545-112(4/08)
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