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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> eikkR 7- 'L -1(1. i �D til.-r ,b,"r ►'I Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> (P?-51 k/lib i (N ,t) g., s-4-. ‘e,1 1 N Q Se 4.., hf t . S 3 S g y Variance(# ) <br /> HOME PHONE (��, CELL PHONE E-MAIL ADDRESS <br /> U �4, 1 q2 I Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> e <br /> AGENT MME NIA Gra 5-s( --� Tef K -a-Nsf-(,•Cf-C6-0 a Site Plan including location <br /> AGENT ADDRESS CONygACTOR ADDRESS of well/septic <br /> 1W h-t-A-0 (ere (?0 4%CY (Z . rr VJ L.. <br /> (C te, p) (Citv 1e.Zip) 'S 3S3 L 9 Setbacks IJi S3S32 �� 4 G - 5 <br /> / <br /> PHONE q PHONE On Site Plan approval from <br /> G(J 8 ; /f Tr r 441 @ Ch ,fie t. `--i- .pplicable township: <br /> E-MAIL ADDRESS E-MAILA DRESS ►7 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/laccessdane.co.dane.wi.us/) ►`I Elevation of property <br /> PARENT PARCEL,UMBER: CURRENT ZONING: ACREAGE: P P rty <br /> PARCEL , -2c(� 4[ p frontage drawn to scale. <br /> NUMBER / • 't) - "12 -c�IOO <br /> TOWNSHIP: SECTION: <br /> 1/4: , ,/4: I�� Driveway permits <br /> ADDRESS: <br /> state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> public,private) <br /> PROPOSED PROJECT INFORMATION <br /> €PROJECT DE CRIPTIO � ..5- <br /> '`; '''g Qe a <br /> . 10 This project is a new building or structure. Cc., q�gy , p. - <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: �; Y ' as <br /> SEWER ❑SEPTIC 1 4Vt 4 <br /> 5-y_ €.. ',-,` ;. - ,• <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) € a ` <br /> AREA TO NEAREST SQUARE FOOT: 1 1 'S _ r R <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ." 4 <br /> ®q a a <br /> BASEMENT: 1ST FLOOR: <br /> •3C\ ,, TOTAL SQUARE FOOTAGE: 4, a� 4;1.,.t`- <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: --c__-> m _ q , <br /> (Please round to nearest dollar) --► "'� --► $ i ) op C7 � , i-,,—.;,-,11 <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? ❑Yes 4lo ❑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 VI No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ' No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► -i <br />