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^ t�d/1C# 1 n S/ re /c /'\c - -1-t;it f crc)714 (ez-lij C-Ott"? <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER::INFORMATION z. '?= d;;� '" �.'-, ^>' 1r, .: CUSTOMER TO PROVIDE <br /> OWNER NAME T,... e . <br /> ' ,telVik ❑ Zoning Status;CUP; <br /> OWNER AA,DDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> B <br /> HOME PHONE -Zruj�CELL PH r WI E-MAIL 1 ADDRESS\ 5 g Variance(# ) <br /> /a. - 3q4,3194 -- • - _IXo` ' 4 • -Calk ❑ Site Plan drawn to scale <br /> AGENT INFORMATION - , ;: CONTRACTOR_:INFORMATION.`:. . „,• and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) LI Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wims/) ❑'Elevation of property <br /> PARENT PARC LNUMBER: ,l CURRENT ZONING: ACREAGE: P P y <br /> ❑ PARCEL 0 1 p _ y `td,•O R`,3A frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/. ,/,/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATIONT <br /> PROJECT DESCRIPTION: t `— [1:4**0101-1'04'P.61-t=,':sff;:ii-1„ <br /> 1= This project is a new building or structure. r r r I <br /> ❑This project is an addition/alteration to an existing building or structure. �� 7*.' � <br /> SANITARY SERVICE: e ar� x <br /> PERMIT NUMBER: �� „� � �* � � <br /> ❑SEWER ❑SEPTIC ) # 1 a <br /> HEIGHT IN FEET: �'�y� NUMBER OF ST RIES: (Not including basement) . _ <br /> AREA TO NEAREST SQUARE FOOT: <br /> i �Yr a r°' �t-4 <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) r-W-1:',-;-.5C n"� t4` Zoo( - <br /> BASEMENT: 1ST FLOOR: a �� ®�a r � <br /> 0 1� TOTAL SQUARE FOOTAGE: 9 t , <br /> a _ <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ / - " r : _ .e „L.,.•(Please round to nearest dollar) •, F cj A a � �.. � • <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? NYes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes to <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 14,6. Is a location survey required? (see reverse) EYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Li Yes T No <br /> APPLICATION MUST BE SIGNED <br /> /�/� x /� çontinue/ C on Back) -► -► -+ <br /> 545-112(4/08) -c_e_e r 19c` J C t l� 5/s7 • //, <br />