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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# . <br /> PROPERTY OWNERt.INFORMATION„ ,:> ;; !; -4 3 ,;.;,; .1,-.' r <br /> CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 42AG� 4 121/ //t'' A Zoning Status;CUP; /©4 Aj a <br /> OWf4ERADDRESS (Number,Street,City,State,Zip) /�7��'�` �� <br /> 3 /� Deed Restriction;CSM �'g/111-- <br /> 3$S% .O�c,Ai-c/1 '1 A.e,•- /4/4) 4 w3 . _3-3 53 / Variance(#/7t/i&1 ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Gcj 71y/303 6441 yyy 7.997 JSite Plan drawn to scale /2-3 <br /> AGENT INFORMATION. CONTRACTOR INFORMATION , and includes di ension • r) <br /> AGENT NAME CONTRACTOR NAME /d rd t.t A /[ <br /> fi Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 0 Setbacks 4 7 27; k <br /> S ' /Or z ” <br /> PHONE PHONE 0 CCSite Plan approval fr m <br /> applicable township:l / <br /> E-MAIL ADDRESS E-MAIL ADDRESS N <br /> Q Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.daAnceR.EAwGLEos/) ') es o p <br /> PARENT P CE1L NUMBER:: URAIR TZON`N ACREAGE: x Elevation of property <br /> ❑ NUM ER 2/ �/�� -��t� / �p , frontage drawn to scale. / <br /> TOWNSHIP: (1,s SECTION: �' /p �' e �G( 1/4: %IA: Driveway permit -, , C c 1' f(rr C <br /> ADDRESS: ,•,_i' ! /r (oe (state,county ., ) /3 `7 �'� r •� t e 6,, <br /> y SanitarYP- rw�Gf:,,t <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public (• <br /> 4 <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: / o / C t ' �s + �Di/�� <br /> This project is a new building or structure. :- <br /> ❑This project is an addition/alteration to an existing tS ' • • • _ , 1.,,.- ; r' <br /> �q #SANITARY SERVICE: NUMBER: j KA I A❑SEWER ®SEPTIC p , <br /> J HEIdot O ( 0t <br /> GHT IN FEET NUMBER 0 • • •• . .. -n <br /> / 2 e <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) �' : <br /> BASEMENT 'p 1ST FLOOR: / • a; <br /> �/ 4 TOTAL SQUARE FOOTAGE: 4, ��- aid" d 1� `� <br /> 2ND FLOOR: 3RD FLOOR: 4/81 • � � I), �j <br /> ESTIMATED CONSTRUCTION COST: 1.1;, , <br /> ►� fie` � �� <br /> (Please round to nearest dollar) '� "� v v vvr •� r � Z� �; ��1���"'�/ <br /> ,cfoork9«. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? AtlYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? G (Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 41Yes ❑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/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 2}No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —* <br /> 545-112(4/08) <br />