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7Lo <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER PROVIDE <br /> O ER NAME <br /> L .q ❑Zonin atus; CUP; <br /> OWNER ESS (NNuumber,Street,Ci St te,Zip) > / �cr ` / Deed estriction; CSM <br /> ��1� ���� rf .�(�Cl�( Yf`J1ll�� .3S�S-- Variance(# ) <br /> HOME PHON 6O� CELL PHONE E-MAIL ADDRESS <br /> �67 .5-2 - ❑Site Plan aw o scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and include imensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan inclVr6 location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of�w�el eptic <br /> (City,State, P) <br /> ( Y El(City,State,Zip) ZIP) Se�Dacks <br /> PHONE PHONE ❑Site Pla. -y•r v I from <br /> applicat et. ship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plan o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevati O property <br /> PARENT PARCEL NUMBER:p/ CURRENT ZONING: ACREAGE: <br /> ❑NUMBER 0206-103- /bAOf,2 II, ` (� frontage wn to scale. <br /> TOWNSHIP: SECTION: 9 ❑ y r <br /> j l C� '/<: '/e'/4: (state y, wn ADESS: / I �QdB1Qc1 JQ` f 0 /� � C r //WfS35/stsa "a :-r i 0 <br /> CSM: !'f �� LOT / SUBDIVISION BLOCK/LOT f <br /> 4/.1)0 CS t 8/4/4-11.2 (pu I e <br /> PROPOSED PROJECT INFORMATION STAFF IEW <br /> PROJECT DESCRIPTION: <br /> 7 his project is a new building or structur� <br /> ❑ Peirmitt Use? <br /> •This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Ryp a re_[EWER /.r 1 'ICe' : ,u, ,,�1 <br /> HEIGHT IN FEET: ` r NUMBER OF STORIE (Not including basement) d� iz, �i ` <br /> AREA TO NEAREST SQUARE FOOT: ''' ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ' <br /> BASEMENT 1ST FLOOR: 7)8 ' , - �s : <br /> v(;;t(J <br /> 4, TOTAL SQUARE FOOTAGE: + (3 e"t„:4+ + 10E�,sti <br /> 2ND FLOOR: 3RD FLOOR: 7^� filling" <br /> ❑A evi q e�.� IS`u <br /> A� <br /> ,'V.� r'Vey- <br /> ESTIMATED CONSTRUCTION COST: ♦ -► ..+ ♦ $ 8� ,f OF1S <br /> (Please round to nearest dollar) $ $c3 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ao ODon'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 f�lo <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 M'No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes /�� o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -9 - <br /> 545.112(4/08) <br />