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. 170.3 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> MaFLI4. QC'TTNE.1?..._ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) 535"4."z- Deed Restriction;CSM <br /> cSS 3 8 ST1=II.aIi_k31z:m=4L GIB., M I C7p1r.�-7 5/1 )1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> $3 I - 7a SS ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> G.4PI'TAL $..)11 47-$ /!vC-• <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 6 4c==o G l$i}dl.r 171Z,ST I— <br /> (City,State,Zip) (City,State,Zip) LI Setbacks <br /> mac.1Sc=w-, 1041 5 3"7/3 <br /> PHONE PHONE ❑ Site Plan approval from <br /> 2 z 2 - S 4.8o applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Cc+)p14'ol bu i Iciers a..-telS,ii .t ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: II EI2VatlOn of property <br /> ❑ PARCEL 04o7_ 07.3~Zelied'- /, 5S frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> S Pit4 is--1 C 'A<F.- 2, 1/4: Y/1/4. LI Driveway permits <br /> ADDRESS: (state,county,town) <br /> 30 CIO 14 t bow V r E.►.I 'nZ•4∎1 c_._ <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> I NI> -AJ RIDGE (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> .-, R <br /> PROJECT DESCRIPTION: : M <br /> S(�.� PAH 1LH AO-.S I E.NC� g ; <br /> Y4 <br /> ® a <br /> . I,�This project is a new building or structure. F + <br /> ❑This project is an addition/alteration to an existing building or structure. °f <br /> SANITARY SERVICE: PERMIT NUMBER: °° <br /> ❑SEWER XSEPTIC 5 I-I 9 w4.. excel a `" <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> lc- . 0�� � 4 <br /> AREA TO NEAREST SQUARE FOOT: ;W <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ••e tiQ # .., <br /> 4 i ne. wG b 4- 4, TOTAL SQUARE FOOTAGE: j a 40° `� v <br /> T , <br /> 2ND FLOOR: 3RD FLOOR: ,; ` '' � " :� <br /> ESTIMATED CONSTRUCTION COST: ! N Y qt+s i <br /> (Please round to nearest dollar) ' -► "+ -* $ 5 SO, dOC)+ '- "� - .e a <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes IiiNo LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? MYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes rANo <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 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes >1:No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4. -► <br /> 545-112(4/08) <br />