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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT#•':W A• . <br /> 'PROPERTY OWNER_INFORIVIATIOIN O UV IML- - '' CUSTOMER TO PROVIDE <br /> OWNER I 1'SC <br /> a�. � u J <br /> OWNER ADD ESS (Number,Street,City,Slate,ZZp) Oning Status; CUP; <br /> ^-pt4irr� �r.. D� „(; t yr y.` i � -� t.t Deed Restriction; CSM <br /> 'fir Variance(# ) <br /> HOME PHONE CEL PHONE E-MAIL ADDRESS <br /> - tre Flan drawn to scale <br /> N ' I 'A ,!.` , ir _5_ , _ 'CONTRACTOR INFORMAT,•;IaN I,. and includes dimensions <br /> ' AGENT NAME CONTRACTOR NA -{ <br /> N Q1 0t ht -- U Site an i luding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS Of eptic <br /> 1 5 ‘0 S, �'oc-i ter f' \. <br /> ity,State,Zip) (City,State,Zip) <br /> r a cks <br /> 5a 1 <br /> PHONE PHONE .] U Site ' an ape oval from <br /> 26 2. - Li 2.-11 15a_ applica.. ownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> kti o 1ti E �•t6or plans . scale <br /> ■ ' * 10 . .O MA .1*N ' htt t//aceessdane cordane vviws -- v <br /> P E ation of property <br /> PARENT PARCEL NUMBER: CURRENT G: ACREAGE: pf0 e <br /> El <br /> PARCEL (� � <br /> NUMBER 0110* (1Z`..-Y621- D% K 'ki, / 0,� 3 52, rontage drawn to scale. <br /> TOWNSHIP: SECTION: , <br /> r‘' '�. �t %a: s.� '/a'/4:i 'i c ODriv- ayp- mits <br /> ADDRESS: (state,co.nty,town) <br /> CSM: LOT Ab SUBDIVISION BLOCK/LOT ❑Sa `ary .- mits <br /> (publ .rivate) <br /> PROPOSED.PROJECT INFORMATION '.i Ts• - n" M k , <br /> Ti AFF 0EV1EW <br /> PROJECT DESCRIPTION:. <br /> COIL ,� G?ch_ JI n1( <br /> _ �� 3P A(�CC _-�nmg D stnct <br /> ❑This project is a new building or structure. _® P mitfed4(40 i <br /> ZiThis project is an addition/alteration to an existing building or structure. , ' _-'� <br /> x:: . <br /> SANITARY SERVICE: PERM UMBE : 1 ® RUral AddreSS <br /> NEWER [EPTIC .�J,n,r-rp \ } (new/ <br /> HEIGHT IN FEET: j NUMBER OF STORIES: (Not including basement) <br /> 1 9 1 R Wetlan .•dplain/ <br /> AREA TO NEAREST SQUARE FOOT: hiirel • 1tactiment) <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> E1 Eros Co- of <br /> BASEMENT: 15TF�OOR: r . I permit <br /> 21 \k 30 Vg` 4, TOTAL SQUARE FOOTAGE j slopes, turbance <br /> 2ND FLOOR: 3RD FLOOR: V �( , 1: filhng�a• e ` <br /> U LI D a <br /> W Revi Location SU y <br /> ESTIMATED CONSTRUCTION COST: a ► aalla fe Ops- <br /> (Please round to nearest dollar) -÷ -∎ ♦ ■ —► $ 3 0 G( <br /> ,t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a /��' <br /> pond or lake? ❑1'es �]No []Don't know <br /> 2. Is there a wetland or floodplain on or near the property? QYes JNo []Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ElYes ONo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? - [_]Yes [2No <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? QYes �No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4108) (Continue on Back) —0. —► —0. <br />