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C 4'1 G j <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> NER NAME <br /> ��'� rS� r/^'�0r'I Zoning Status;CUP; <br /> V7N OWNER AD RESS (Number,Street,Ci State,Zip) <br /> 2 3 � �r , �� �, , ,ej`w C Deed Re(triction;CSM ) <br /> 'l �' ice' .S- � Variance # <br /> HOME PHONE C LL PHONE" E-MAIL ADDRESS <br /> 15°zc&'t- , //,1 'l Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .—s ' e _ k; Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> �, p • <br /> (City,State,Zip) o <br /> (City,State,Zip) Setbacks <br /> /PHONE PHONE����,�� �� ^�� CkSite Plan proval from <br /> =r$/ yyz 2 applica township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS ///-� <br /> �c viler e = Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn Elevation PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: evaon oproperty <br /> ❑ PARCEL �s //� L frontage drawn to scale. <br /> NUMBER CV 7��3'zZ ��0'7 /��- 2�z/ <br /> TOWNSHIP: SE I N: <br /> �S �/ %73 %: N W %l/: 5 p Drivewaypermi s <br /> ADDRESS: state oun ,town) <br /> ID <br /> i ❑ Sanitary permits - b <br /> CSM: r7Z Z LOT SUBDIVISION BLOCK/LOT (public,private) <br /> -5,/Livt <br /> 4 <br /> PROPOSED PROJECT INFORMATION 7 � <br /> PROJECT DESCRIPTION: <br /> P �z � € tix <br /> L his project is a new building or structure. �� � <br /> ❑This project is an addition/alteration to an existing buildin• or e. ,, <br /> SANITARY SERVICE: iiir:hII: o� � e a _ <br /> ❑SEWER r EPTICt -, 1 4 L <br /> HEIGHT IN FEET: NUMBER I'. • incu•ing•. -�� <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porche a `° <br /> f � �l' <br /> BASEMENT: l 1ST FLOOR: £ �^-- , A� O CO/C � <br /> 3�`y/ 4, TOTAL SQUARE FOOTAGE: 4, aka•- sl - i u `� <br /> 2ND FLOOR: 3RD FLOOR: p� <br /> A '' <br /> ESTIMATED CONSTRUCTION COST: <br /> ♦ ♦ ♦ -► ♦ ♦ , - t • : •a s °, <br /> (Please round to nearest dollar) $ ����� M Tr-.. � �" <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ,o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Attlo en+kne r <br /> 3. Have you talked with the township about your project and are they in agreement'? Egks ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes IP <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# /C., ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes EINo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ,INo <br /> 0,c k c'l f�� S),q / e— APPLICATION MUST BE SIGNED <br /> `� (Continue on Back) ■ ■ ♦ <br /> 545-112(aros) L <br /> 1 1.0..'1 po id— C--;,,f%sP G cIS <br />