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(CB t 2 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> &l 0( i A- enk) thrtAlciAlca <br /> ❑Zoning St tus; CUP; <br /> OWNER ADDRESS umber,Street,Ci tae,Zip) <br /> 027h ., 6 + ,,e Y t CAS PM"-; � w.0 Deed Res n; CSM <br /> HOME PHONE CELL PHONE J E-MAIL ADDRESS r,� Variance(# ) <br /> 6 U 2 s� 94e) Joiti 4.0 It I '�- 914e5S•"ND Site Plan r n to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and inclu s dimensions <br /> AGE/1T NAME CONTRACTOR NAME <br /> not St a-6) f., ❑Site Plan i cl ing location <br /> AGENTA E • - CONTRACTOj A RESS of well/sep I <br /> (C` State,Zip) � � (City,State,Zip) ❑7et LkS �t V/ l / <br /> PHONE /, PHONE 111 Site PI.A. -• val from' <br /> 6 U g73 7%C applic f. : <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> WI S ()TA 1 C 6-M4/Leal Re Z pZ ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT R L NJ R ACREAGE: El Elevation n of property <br /> ❑PARCEL � flail_17Z 4 '' O <br /> CURRENT k+ / fd\ , frontage <br /> drawn to scale. <br /> NUMBER <br /> TOWNSHIP: h \SECTION: <br /> ! ' � �-le f 7 // ❑ Drivyay • its <br /> 14. 1414. <br /> ADDRESS:�7 � 6,t 1 ,,r 0_,) (Sta�', ,O t <br /> CSM: LOT SSUBDIIIVISION BLOCK/LOT ❑Sanita pe its �[�j��j <br /> �7/ (public, ' ate) <� "�'" <br /> l 6' i i <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 61r(L.AO L... 30I to x 261 D ❑ Zoning ' trict <br /> . his project is a new building or structure. Permitte se? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addre <br /> EWER 'TIC NU' r� (new/exi Ing)) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 0 t 5 ❑ Wetla /F ., .in/ <br /> Shor I 'n ( t..hment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErOSI• C•, ermit <br /> - - 1 TOTAL SQUARE FOOTAGE: 1 (SIO•fl • to bance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 701 <br /> flllln•/access) <br /> „:70,3 <br /> ❑ Revie Lo Sy <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ I b(� 0 and ava e ptio <br /> (Please round to nearest dollar) $ l/ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Dies ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Elves ❑ <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Elves [ No <br /> 5. Is this project associated with a rezone/CUP/variance(peti ion/appeal# , ) r (leave blank if none) <br /> 6. Is a location survey required? (see reverse)..1.1.44A1,f V e ,h.(..e.e..(1 ❑Yes ❑N. Don't know <br /> 7. Is this to correct a violation? Eves L, o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -+ <br /> 545-112(4/08) <br />