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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to'Web-App# <br /> PROPERTY OWNER INFORMATION . . :,°'„',' ';5},1,0,;, 4:::,: r, 1: % CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 77-10MAc, 3r�ilk'gf)(0 Low t:' ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction CSM <br /> ►S O K/, FRAw`t 57 C f)2Y, I L 60013 Variance(# 2)5 23 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> or?-�31- 7E35 b)OWe 6) m c•0-et ® Site Plan drawn to scale <br /> AGENT INFORMATION:-: ,.' CONTRACTOR•:INFORMATION; and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5 ETZI<E c A RPC i ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 3o( Firz5/ 4, . <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> 6RAI(Ot Du sAc <br /> PHONE PHONE © Site Plan approval from <br /> 6o8-c 4l3-22(7 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.danewi.us/) , <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 090-7 -03a,-4110 -9 <br /> TOWNSHIP: SECTION: <br /> R0 X$U 16 ; -/: 5 w -1/41A: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ?6 (-715t1 LAKE 20 )AUK CIi <br /> CSM: LOT SUBDIVISION_ BLOCK/LOT ❑ Sanitary permits <br /> 10 4 f1USCLS /-15/4 LAKE (public,private) <br /> 5U50 <br /> PROPOSED PROJECT INFORMATION A �E <br /> PROJECT DESCRIPTION: ,€- <br /> PE&1ILT EXISDP6 S,IEO RE LACED co,(/(RE TC ' iVoP ® gl b ffi <br /> ❑This project is a new building or structure. a <br /> ®.This project is an addition/alteration to an existing building or structure. AI-, V ,-• <br /> SANITARY SERVICE: PERMIT NUMBER: t' °° ,, V <br /> t �� <br /> ❑SEWER 0-SEPTIC �� �° ��'"�� <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) -��. "' .- " ' <br /> I Z r ► I amtw e yew 1 ) �` <br /> AREA TO NEAREST SQUARE FOOT: - ,-- �- , ' / , U '.-+ <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) x * <br /> e ° p ° r A <br /> BASEMENT: 1ST FLOOR: : _ - r -,- r- <br /> ,, TOTAL SQUARE FOOTAGE: j ° a a <br /> �° o �._ � ) <br /> 2ND FLOOR: 3RD FLOOR: igg t �: <br /> 11 1 Q. SG/ F. <br /> ESTIMATED CONSTRUCTION COST: a <br /> (Please round to nearest dollar) '"'� '� ''' •"P "'� •'+ $ L9,000 � -..° �) t•t•"°_E tjaItita <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 0 Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®No LI 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/va iance4pe1ition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse)... -.DANE. ' r ®Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? Si Yes ❑No <br /> MAY ? . 2008 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -► <br /> 545-112(4/08) <br /> ��!R' r <br /> l i, , i. I.°,E i�ISION <br />