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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CU-TOMER TO PROVIDE <br /> OWNER NAME <br /> ��.-:35b� 4'C-4-1-g-/5� <br /> T(3 -)10 I reed ping Status; CUP; <br /> O WNER <br /> ADDRESS (Number,Street,City,State,Zip) 0 CE t) tt ppQii_fte_t _3 Restriction; CSM <br /> ariance(# <br /> ) <br /> HOME PH NE CELL PHONE E-MAIL E <br /> . 0— Il ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION n includes dimensions <br /> AGENT NAME NNE <br /> 1 i-1 $ tEJ 4:='t eci LU i Od (_ ,8 it/-jJFR • e Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> ,362?' 6°1-37- 7e Cf t3.S 5 1)0( <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> 6�cto State, , t"/ 5— e c <br /> PHONE PHONE ❑Sit Plan app al from <br /> Y3 — 'r?/P t a licabl wnship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ) u-kf,,-p Gee./NE loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PA EL NUMB 1: CU ENTZO G: ACREAGE: Elevation of property <br /> ❑PARCEL df I / ^ . 02 Ott/�� � 7 frontage drawn to ale. <br /> NUMBER I 1 <br /> TOWNSHIP: SECTI � 1 \�t 1 <br /> 8P--1 .! 4 f^' '/4: <\r\•i 1/41/4: \ <br /> ❑ Driveway mits <br /> ADDRESS: r r (state, unty,town) <br /> ?/3 L li-616 E R-5 >f l t)'YR L ❑Sanitary permits C <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> /suele5 (public, private) <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 19t SS .M7Ok) ■ • ing District <br /> ❑This project is a new building or structure. <br /> ermitte• se? <br /> project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PER NU`�M��B,,ER: LI Rural Ad,ress <br /> EWER 54EPTIC (J�— Z. (new/existi • <br /> ■ <br /> HEIGHT IN FEET: NUMBERJpF STORIES: (Not including basement) <br /> ❑ Wetland/Flood / <br /> Shorelan chmen <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> ❑ ErosionContr ermit <br /> -prTC1=' - /�(' ' + TOTAL SQUARE FOOTAGE: 1 (slopes,d urbance, <br /> Y''C J1 filling/ s) <br /> 2ND FLOOR: 1 3RD FLOOR: 2 <br /> g� —., >$._ 4/J.s. ❑ Review Location Survey C- .. <br /> ESTIMATED CONSTRUCTION COST: $ ybb 00d CZ and available options. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �P r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes EINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes to ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? EYes 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) Eyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes EINo <br /> ` J� ♦ ♦■APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i <br /> 545-112(4/08) i <br />