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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> GOV.y c`'/�a r h`'y PlC J<� r OPA Zoning Status; CUP; <br /> OWNER ADDRE S (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 5 GS e i/f ere / oo/) Rae Q.- -c-,c,A' IL";.,,cg-5-7,S Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> g).33--_4-6,7c, r t.s " 171 F.1 �G '/9.-047Y.i1 ' .Co•m Pis\ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME CONTRACTOR 94,ME <br /> _ce/ PA ' - ` an Inc ••in location <br /> AGENT ADDRESS CONTRACTOR ADDRESS ` of well/septic <br /> (City,State,Zip) (City,State,Zip) 'A Setbacks Z-f f/ij <br /> W. <br /> PHONE PHONE ' Site Plan approval fro <br /> -pplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> r'A' Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) As <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: l,, Elevation of property <br /> ❑ PARCEL �/ ;� o rontage drawn to scale. <br /> NUMBER 0T.2. oScl9—X33°Q37�S L\ <br /> TOWNSHIP: � O�-� SECTION: '/a: S �` '/4'/4: /�.f fr' Driveway per,;,-- <br /> ADDRESS: state,coun. own <br /> 7 ? 1W r P' Gk S 6e 'A` Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 10T ....0(Y44,-.e K)ba-F / public,private) <br /> PROPOSED PROJECT INFORMATION F -•-<� _`4. / w <br /> PROJECT DESCRIPTION: ' ' "i <br /> . ❑This project is a new building or structure. -�� <br /> flip/1�� a 4 <br /> XThis project is an addition/alteration to an existing building or structure. ' : : <br /> SANITARY SERVICE: PERMIT NUMBER: '-'"L u 'i��` zo'Jg--. ;, r <br /> ❑SEWER PTIC 4 ,.� -=:.-t4'.... ...-----!-- <br /> ri <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Y <br /> 1 ? tH v1::.,4*.e:iottot-00-0*-4), ,i.f�-w g ~�t„ �, -'AREA TO NEAREST SQUARE FOOT: 2,7 T <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) > - '` <br /> BASEMENT: 1ST FLOOR: ® s <br /> S g- 4, TOTAL SQUARE FOOTAGE + ` � ` .• ifs * ..-, <br /> 2ND FLOOR: 3 FLOOR: 7�� j�^ { �kr � 'z � " k <br /> l SJ � y 3z a` 3'a . <br /> �/ Yuix�^' Fl-F" ®0✓ 1810 SR <br /> ESTIMATED CONSTRUCTION COST: o • air p' ,-15• <br /> (Please round to nearest dollar) '� '� ���� �, = r,:• . - .-1 , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L`7 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 31-Cio ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes �0,N�o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 1Wslo <br /> 5. Is this project associated with a rezone/CUP/varian - .•- •• .••eal# ) (leave blank if none) <br /> 6. Is a location survey required? (s-- ,e - ❑Yes L I N�o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes L'1 No <br /> 21 APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -► <br /> 545-112(4/08) <br />