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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION' CUSTOMER TO PROVIDE <br /> OWNER <br /> DRE 4 <br /> J77 74 i>41-6/#9 "7'5'9,4/"7'5'9,4/OWNER AD SS yt�i+mber,Street,City,State,Zip) El Zoning Status ; <br /> 013 C-7norV Qa/ j�i�4/2' S/ 3 7/( Deed Iction;CSM <br /> HOME PHONE CELL PHONE MAIL ADDRESS <br /> ZZ)^5-q1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> A ENT NAME /� C TOR NAME <br /> / / 4,,v T'//Ls ❑ Site Plan i I g ocation <br /> AGENTA•:-ESS CONTRACTOR DDRESS f septic <br /> /Z33 W.O,/u,4 vrc4 C C-74 _(City,state,Zip) Ci te Ip) /Setbacks <br /> �7.4/ , N.7— S3.s-FS9 <br /> PHONE PHONE ❑ Site Plan a•• :•al from <br /> g 73 — lq3 s a plic-_ - township. <br /> E- .IL ADDRESS E-MAILADDR.SS <br /> de- , -r-as ,t6._+- F •or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://Eccesssdane.co.da a wGE sn V Elevation of property <br /> ❑ PARCEL 0�D O —Q/a 1 - 1 9 ..Z frontage drawn to scale. <br /> NUMBER 1 I <br /> TOWNSHIP: SECTION: DrIV @Wa 'S <br /> vnn S 1/4: 5 \N1 1/4/.: IMF CI ADDRESS: S county,town) <br /> i 3 -ANt. rsk ' r� �Grl ❑ Sanitary permits <br /> CSM: LOT a SUBDIVISION BLOC OT <br /> 7 wi r s [� —.Z" Fd� (publi ;private) <br /> PROPOSED PROJECT INFORMATION <br /> P';b JEC I•ESCRIPTION: A k I <br /> ❑ his project is a new building or structure. ' � � <br /> if_ &� <br /> This project is an addition/alteration to an existing building or structure. '� ' ,4'' <br /> SANITARY SERVICE: PERMIT NUMBER: '�� - ��� <br /> ❑SEWER SEPTIC `.� s � �fi <br /> HEIGHT IN FEET: ( G / NUMBER OF STORIES: (Not including basement) " <br /> om' a aC1 , <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached arages and above grade decks or porches) ,° ��; <br /> BASEMENT: 1ST FLOOR: • $ i <br /> ��� �, TOTAL SQUARE FOOTAGE: �, 1 • g 1 a c a ,t <br /> 2ND FLOOR: 3RD FLOOR: I -. tom" E ,. � <br /> ESTIMATED CONSTRUCTION COST: -;r 4o • .is,- <br /> ♦ —► ♦ -+ —► <br /> (Please round to nearest dollar) �, �. Z_ f: - ,S <br /> /-S 0) ti 60 r— ,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ayes 1=Io ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑ es LdNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? a Yes ❑Mo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes LJ No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan_kf'� one) <br /> 6. Is a location survey required? (see reverse) ❑Yes l.� ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —I* —• —P <br />