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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> l <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> i Cif a(tPV 0 Zpning Status; CUP; <br /> OWNERIARDRTS (Number, tit,City,State,Zip) // Deed Restriction; CSM <br /> 77 NA(Number, v �I)/ f4 w / rI�d f -e U4-- l'3 U Variance(# ) <br /> HOME PHONE / %ELL PHONE E-MAIL ADDRESS <br /> /� �` 3/ 7 '19 §t'e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION And includes dimensions <br /> AGENT AME CONTRAC OR NAME <br /> S e e ct/ / Z 7�'� �r a <br /> Z te Plan including location <br /> AGENT DDRESS ` CONTRACTOR ADDRESS bf well/septic <br /> 7 3 70 bt/y I icf ro /J i 1 m <br /> (City,State, ) r r. (City,State,Zip) L2 Setbacks <br /> 51(Pi rel4 frt C dr <br /> PHONE PHONE Elgite Plan ap val from <br /> 2 7 9`,-.7ag- ,'applica ownship. <br /> E-MAIL A DRESS E-MAIL ADDRESS l <br /> rce/fZ y Pe Q 6kil 4.r f Cd e- <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PAR"LNNUMBER: / Q y) (CURB ZONING. ACREAQE: WI p p y <br /> ❑NUMBER U /i- /.8/ ,e.gwo , `l I 1 • frontage drawn to scale. <br /> J / 1 <br /> TOWNSHIP: SECTIO". <br /> t S Q '/4: '/0'/4: I V L._ ❑ Driveway permits kit <br /> (state, county,town) �' <br /> ADDRESS: ) ' 1 (� <br /> C�/[ r vQ ' ❑ Sanitary permits I I <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> /I 7 / <br /> 11 ? I (public,private) ,e S . <br /> PRO POSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> fi P w / �O y,) P YZ9ning District <br /> . <br /> This project is a new building or structure. ❑Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. y-� <br /> SANITARY SERVICE: PERMIT NUMBER: OL.I( al Address <br /> FIEWER WEPTIC f.3 '�O t ^ OW l !(new xisting) ,__.--- <br /> HEIGHT IN FEET: NUMBER OF STrRIES: (Not including basement) ,.--'J <br /> ON Wet an £Fioodplain/ <br /> AREA TO NEAREST SQUARE FOOT: and (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) i <br /> 1ST FLOOR: f 1 Er9sionCon Edi permit <br /> BASEMENT:(Z)1/45.....c (3 7 <br /> 4, TOTAL SQUARE FOOTAGE: + (slopes,dfisturbance, <br /> 2ND FLOOR: 3RD FLOOR: �✓ l 9 felling/ CCeSS) <br /> q 1 <br /> ?Review Location Surve <br /> ESTIMATED CONSTRUCTION COST: -► ♦ ♦ ♦ ��� Q /� and available options. I \--- <br /> (Please round to nearest dollar) J ,( <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ao ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes ElNO ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? MYes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Lives 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) Elves No ❑Don't know <br /> 7. Is this to correct a violati ? Lives [' No <br /> L_ APPLICATION MUST BE SIGNED <br /> (/t i -9!.......c (Continue on Back) -► -i <br /> 545-112(4/08) <br />