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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> CUSTOMER TOMER TO PROVIDE OWNERN,f64 I q Je'lxVaJ LliaC11 ❑ Z oning <br /> Status;CUP; <br /> OWNER ADDR SS (Number,Stre pity, fate,Zip) A , Deed Restriction;CSM <br /> 2 q�� (j�j, G/a .s- nv� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Lf 1`--03/1 a-Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME.. / <br /> CONTRACTOR NA E <br /> 0 5-Ve v� �GC <br /> Lr� rU((dQVS �ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (Z 1-( 1 LA//If I"l tswl s 1 _ • <br /> (City,State,Zip) f � <br /> (City,State,Zip) n Setbacks <br /> PHONE G�-e1 J PHONE ❑ Site Plan approval from <br /> Z 67, ( te--/.( applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Sfeu -f Q■-14.46/es 6v,(ley{ .c , , Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: )U Elevation of property <br /> D PARCEL ote 0(01 d_oSyZ37?- s frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • b Uyt\ S--,v ) 14: 5,V 1/1/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> z_qc.,2 (,r,/6'U64 t.4.- <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION '.- <br /> PROJECT DESCRIPTION: /y/) = . , - i <br /> ❑This project is a new building or structure. z r t <br /> his project is an addition/alteration to an existing building or structure. �, , -, , � <br /> SANITARY SERVICE: PERMIT NUMBER: s s <br /> $ <br /> `SKEWER <br /> ❑SEPTIC ', a ,+ t- c <br /> HEIGHT IN FEET: NUMBER OF ST•RIE•• (Not including basement) �s F <br /> AREA TO NEAREST SQU•,-EFOG : v Y <br /> (Outside dimensions including unfinished area,attached g. age .nd above grade decks or porches) - � '-' fi : <br /> BASEMENT: I 1ST FLOOR: s ® �, ' �= a <br /> (.1 //4 (0.Z., ,, TOT• SQUARE FOOTAGE: 1 6 a��s <br /> 2ND FLOOR: 3RD FLOOR: -: 7--- <br /> ESTIMATED CONSTRUCTION COST: �._1 € <br /> (Please round to nearest dollar) •0 ♦ --► "� '♦ -+ , _- '-0 6 0 $ ' e q -� . <br /> I( ) _�_- r � �.'��� �-tea, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? fifes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes .I❑'No ❑Don't know <br /> 3. Have you talked with the township about your REGEDI y agreement? ❑Yes 0 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes allo <br /> 5. Is this project associated with a rezone/CUP/variance(pe i#lonL�ggeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) AN U lc UUZZSS CI Yes ESNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> DANE COUNTY P't.Afrir;; a&d tLG"4``.T <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ -► -1 <br />