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. .3-SS ---t <br /> - ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 11 / <br /> rid 61 r Aj4.ilQ.JIt 16l1ev 'Zoning Status;CUP; <br /> OW RADDR SS (Number,Street,City,State,ZIi�) _ 1p <br /> t oL atop,' - L CI, • ,N`� l/ r b w,.. 535 eed Restriction;CSM <br /> t t'fD i Variance(# ) <br /> V HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> O - °I61 1i-10 s Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION -nd includes dimensions <br /> AGE IT NAME CONTRACTOR NAME <br /> 'V('MI Ce1r M s kt *Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 73 qi. owe, ylopi.e, 'fri I - <br /> V/- <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> Hu cf�1 w� 5317 <br /> PHONE PHONE Al Site plan approval from <br /> 603-343-31,67 appticable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> .(Era 1'I s kr- e eoh %e.C floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ��� Elevation of property <br /> NU <br /> NUMBER 0S O�j'-O'3-9 11160 PP- ( �.11 1 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> -Derr u j'J ' : S(✓ 1/41/.: Driveway per <br /> ADDRESS: I i (state,county,town) (, <br /> • r !�- dr anita -.- .1 its <br /> CSM: LOT SUBDIVISION BLOCK/LOT publi. • 2. -fr <br /> /25D <br /> 3 _ <br /> PROPOSED PROJECT INFORMATION 1 <br /> PROJECT DESCRIPTION: -,_„ -,,,,a;-::- . ,- 'if.-4.5-..-, <br /> ) ` ` .yid `i- - <br /> . This project is a new building or structure. f ® <br /> ❑This project is an addition/alteration to an existing building or structure. _ 7 t � t <br /> SANITARY SERVICE: PERMIT NUMBER: 6 -7- <br /> ❑SEWER SEPTIC ■ 6 I a � x :' --5 h,cv,-, <br /> ?r yk <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) : -> <br /> AREA TO NEAREST SQUARE FOOT: !o rv\ <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) "':::V ` 1 otck �?„■ <br /> BASEMENT: 1ST FLOOR: r �1 ,.,�� � ( �� <br /> f'f l sift, S /i 1 TOTAL SQUARE FOOTAGE: j ,. �. , <br /> 2ND FLOOR: 3RD 0 ,, ��3� �� (- <br /> ESTIMATED CONSTRUCTION COST: $ ; z.°t . :. - ®i <br /> (Please round to nearest dollar) "� •P /n��/7` J� :� � � <br /> / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes CANo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Cgi No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? EYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? igYes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 'l%tI ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Li Yes IgNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IZI No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) <br /> (Continue on Back) -I. -0. —► <br />