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/61 t 01 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N E <br /> 0sg1 J\ .%� 0 Zoning Status; CUP; <br /> OWNER ADDRESS ( mber,Street,City,State, ' <br /> -64 140 0\gl.. Deed Restriction;CSM <br /> HOME PHONE CELL P O E Variance(# ) <br /> E- AIL <br /> kg) 11 ti , ` ... ;l s „_ �"1„ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> A NAME (�(� TRACTOR NAME <br /> ��� ` �`gu� S, �Y1f� h�C 'Site Plan including location <br /> AGENT D ESS CONTRACTOR ADDRESS of well/septic <br /> 511 Vn M �i n N(te R) <br /> (City,State,Zip) i Stat Zip) Oetbacks <br /> PHONE ` q PHONE 0 Site Plan approval from <br /> 6 4` (A 1, 1,(�j t4c4 -71L6 applicable township. <br /> E-MAIL ADDRESS A/ E-MAIL ADDRESS <br /> 1' !, , Z/Floor plans to scale <br /> ■PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CIARENT ZONI�IQ: ACREAG : levation of property <br /> ❑PARCEL �J� C/�Q G� (, frontage drawn to scale. <br /> NUMBER l Cl J�( 6v w — 4 Li � g <br /> „j91C1A{SHIP: SECTIO ❑ <br /> (xd�U U R u �w+.�1 '/: 0 '/h:.aC.. Driv Its <br /> ADORES �_ (sta n town) <br /> �� O O& Sanitary <br /> CSM: LOT SUBDIVISION BLOCK/LOT permltS `J ` <br /> �. $ (public,private) <br /> PROPOSED PROJECT INFORMATION " <br /> PROJECT�ESCR,PTION: <br /> �'�c7>� ❑ Zoning District <br /> OThis project is a new building or structure. ❑ Permitted Use? <br /> .This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER ØEPTIC (new/existing) <br /> HEIGHT IN FEET: A NUMBER OF STORIES: (Not including basement) ' <br /> 9 . �•.5 ❑ Wetlandi odplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shore (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: i /.4/.' 1ST FLOOR: "� Erasiort�ontTOl"permd <br /> 'LOC*7/` --•—• Li I L ( . . _ 9( ' + TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: • ? 3RD FLOOR: 1 2 /� rig a ) <br /> 1(,x21 If I(° , l-2'I8 131 1 ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: -•,. -4. -4. -4. and available ns <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ligsto [Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes o 'Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ' Yes Lo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes lalo <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 o [Don't know <br /> 7. Is this to correct a violation? [Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► ♦ -4. <br />