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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Dale, s Rot91rt 21A.1 Ver1,4-,--14e.1r'
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP;
<br /> 75,26 S4-e Awy taa, 5.L-k ct , u3,• S3 s-3 Deed Restrict/ n;CSM
<br /> Variance(# r?
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> wtr-V41-3-.gob y
<br /> LI Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> 6111 -e.1 5 W i t$pc).-44.A- W,9 ee►-' �"44. CL-nA..4 k I►..&. ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> I1010 Lort C___+ 828 (hd,--,,A-I-y Ral,
<br /> (City,State,Zip) (City,State,Zip) ( ❑ Setbacks
<br /> s -k GI-, vt, 5-3seC3 54....„.k. c, / w, 5-3.8-4-3
<br /> PHONE 1 i PHONE
<br /> ❑ Site Plan approval from
<br /> d B-6 4-3 - t,,tv t3 (a' O S -643 - L?6-7 applicable township.
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http:/Iaccessdane.co.dane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property
<br /> ❑ PARCEL � 'V7-Q7YA opo ' 4-/ .Z frontage drawn to scale.
<br /> NUMBER '1 /I/ �/
<br /> TOWNSHIP: SECTION: 7
<br /> Rax g,Lay NE 1/4: 5E y1/: LI Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> 7S2(. 5{-1Jc r i bE,, S -1.- c-4-77 , 0-1:, s 35 3 ❑ Sanitary
<br /> CSM: LOT SUBDIVISION BLOCK/LOT permits
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION
<br /> PROJECT DESCRIPTION: _ ,:
<br /> '
<br /> " iN ew 5t -)/a ci,ec2 2 c-4-v-d L,- - I Z c 2 L��G -4
<br /> h a
<br /> This project is a new building or structure.
<br /> t 4.
<br /> ❑This project is an addition/alteration to an existing building or structure. .
<br /> SANITARY SERVICE: ': e= ?w
<br /> PERMIT NUMBER: 3,r -t�"" �'
<br /> ❑SEWER SEPTIC 1fit a w 5
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) V «ry
<br /> " ® ,. q.',., t)
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) bli�",:o _ntr nl-
<br /> BASEMENT: 1ST FLOOR " " / te
<br /> lie-2-2.- S c 4-. I- off, 4',4 j. TOTAL SQUARE FOOTAGE: " j a,
<br /> 2ND FLOOR: 3RD FLOOR: 1/ // '=�'t " i
<br /> zy.sk Sb. F{M.
<br /> €
<br /> " t " w ESTIMATED CONSTRUCTION COST: .,.--0 � D` "-∎ i $ 2 2 , b •(Please round to nearest dollar) t
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑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'? TYes ❑No
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? El 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) ❑Yes ❑No ❑Don't know
<br /> 7. Is this to correct a violation? ❑Yes ❑No
<br /> �
<br /> ' 0 ry 15 r.... 301 APPLICATION MUST BE SIGNED
<br /> 945-112(4/08) j,4 (Continue on Back) --• -►
<br /> 351
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