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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT;#o Wep App# <br /> ROPERTY ONNER3INFORMATION.: _ . ----;: �_ -.ti ;Z CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> U .t,U, 6 I Yv1 S <br /> EgOning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zp) Deed Restriction;CSM <br /> I3 Q.Li Counv1`-t A- "-'7 w. s-7D041 t41--tvo I LC- 535-3y y variance(# ) <br /> HOME PHONE CELL PHONE E AIL ADDRESS <br /> too 3'aS-9c00 5' 7 d ADDRESS ,vise' c)o/S.n( fr' Site-Flan drawn to scale <br /> AGENT':INFORMATION, ,;.CONTRACTOR;INFORMATION_MV and includes dimensions <br /> AGENT NAME CONTRACTOR, ME <br /> APC2o1J I--arr10 /1- S ,LS 4+, as ge-W}Gde-1146 I'►c • fli Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3acx s tan-,L.er '2.0 _ Po bvc 7 <br /> • <br /> (City,Stale,ZZp) (City,qtate,Zip) Ra8 tbacks <br /> 5 1 0 gtt:, t A t x.. S'S5i0 Cot 1 t Cie air( wZ 53sa. ) <br /> PHONE PHONE ❑Site P1fap approval from <br /> • 44)`t3-`5 3S-Oa-75 (F0b- ea S-9C(:)(-) applic township. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> aelybin @ 51 m6 ex-ter/VS 'I1e--f- �or plans to scale <br /> _n <br /> • • - '•CAT • • - a .6 c _ . `- .1 k ---. -_ fi ,_v on of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG • Lei P P rty <br /> ❑PARCEL � I L/ frontage drawn to scale. <br /> NUMBER OS/- os •t QsG , n R f"4 <br /> TOWNSHIP: . SECTION: <br /> ^I b%0 v- <br /> v.: A. El ay <br /> (state ty,town) Iy ADDRESS <br /> i3 C(1 (1 1-t lit <br /> ❑Sanitary permits - u L <br /> CSM: )-O . LOT SUBDIVISION BLOCK/LOT (publi , nvate ��'f <br /> PROPOSED PROJECT INFORMATION * x"z`STA "�. <br /> PROJECT DESCRIPTION: n ' ,' "�-"-�� 'VIEW <br /> 1\e JAY- k r <br /> ting�Dls�rict �4 <br /> ❑This project is a new building or structure. e�mltfed Use? <br /> • --15 4 ; <br /> [This project is an addition/alteration to an existing building or structure. _ �.i,� 4 ,• <br /> SANITARY SERVICE PERMIT NUMBER °E1 Rural Address, 4.,• ,-•"`,;)w..asp• - .' w,, f J . <br /> 1.-- EWER EPT1C Cne ' •1 i: z <br /> HEIGHT IN FEET-, NUMBER OF STORIES: (Not induding basement) 4,.; p Y <br /> V �l rWetla d/FIoodain/ <br /> - -tr..Y <br /> Sho a an o atechment) i <br /> AREA TO NEAREST SQUARE FOOT: .*4 :: r...fit. , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) -Y o ...- � tF <br /> BASEMENT: 1ST FLOOR -r r x C . .. R <br /> t4� r 3 C 4,TOTAL SQUARE FOOTAGE: j (( y y �/�/'� <br /> v SIO• • Cj/ <br /> 2ND FLOOR 3RD FLOOR / a„ ;.k ".n 3. <br /> . PI iew Locatl•Disciry ° <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ nd aviIl�,bfg t>�t•.��, *;: 1•Please round to nearest dollar1 R; 3 <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 al. ['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 ❑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) Efres ❑No ❑Don't know <br /> 7. Is this to correct a violation?- Elves "lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4108) . <br /> • <br /> • <br />