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I 1,\k1 r 90 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 5 h der <br /> de <br /> '� ErZoning Status; CUP; <br /> OWNER ADDRESSI,NumbeLptreeWity,State,Z' ) <br /> 14 q D V►'k lS e►►1 / r' 3 ?(, `l Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Ace 1?l 9 9 77^' g ? ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME p , <br /> S 4 wt CC, R' 11( o voS E'�Q p1 i,vil.)‹to KS lasie Plan including location <br /> AGENT ADDRESS CO ti R CTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip viClliVlo� etbacks <br /> 1A/14 Q001A ` tA9 l 5 37 0 tt <br /> PHONE PHONE �, ite Plan approval fro rgi k <br /> 2'�ep ` M (? 877- 9 iS9 apple ble township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> lour plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: levatlon of property <br /> ❑PARCEL O I g/671 -3 ( — $7/D - c p \ Q 9 1 frontag rawn to scale. <br /> NUMBER F� <br /> TOWNSHIP: SECTION: A <br /> • Gofh4ie Doe- 33 %: SE %%: N1,} veway permits <br /> ADDRESS: � A (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT anitary permits h <br /> (public,private) /�' <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: R' <br /> � ,., <br /> odd Cilc iing District <br /> . Ems project is a new building or structure. &I Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: L I_RUraIAd. •- <br /> EWER NEPTIC (new/e 1^ <br /> � <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) •: W <br /> ' ❑ W- - '• loodplain/ •, r e <br /> horelan. (attachme t) <br /> AREA TO NEAREST SQUARE FOOT: s. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) rosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> l TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: / <br /> eview Location Survey 1(/�// <br /> ESTIMATED CONSTRUCTION COST: ♦ —1. ♦ —g. —I. and available options. <br /> (Please round to nearest dollar) 60 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes to ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes '4o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? [ Yes EIN. <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? gees ❑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 EliNo ['Don't know <br /> 7. Is this to correct a violation? ®Yes IDNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -it <br /> 545-112(4/08) <br />