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(1). ifc?-7 pqo . , )_.4h <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ifermo avid (Y)gef itioimp / <br /> 0 Zoning Stat s; <br /> OWNER ADDR-ES (Number,Street city,state,Zip) ���/,; ��. Deed Restri n; CSM <br /> 714 /6V ii7 seM St% (af?br'�"gei Y>1. 535.23 _ Variance(# <br /> HOME P ONE p CELL PHONE E-MP)ILADDRESS <br /> & 1.3 -/Pi in,hoz e e, ahoo,Com Site Plan draw t Cale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes di ensions <br /> AGENT NAME i i CO TRACTOR NAME pp gIck I- er ,Northern h _ hse <br /> &files in Site Pla i ding location <br /> AGENT ADDRESS CO TRACTTO,R ADDRESS J of well/s tic <br /> (ci 73,z+pi `�`cJ 1�l kd Setb fcs <br /> (City,State,Zip) �/ y <br /> re , � <br /> YSo <br /> 'PHONE P ON —' Site PI-n . -- oval from <br /> '7,(, 635--, 9I appli•='let. ship. <br /> E-MAIL ADDRESS AIL DDRESS r <br /> r`k(kQ, er� !di la u- ii.k_ * ❑Floor pla s o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.darie.wi.us/) El Elevation f pr arty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ frontage to scale. <br /> NUMBER al i7: 3Cst 17�� "� �-i�f r7 � J/ <br /> TOWNSHIP• CC ION: <br /> Deeff i ati v.: Ng '/h: ❑Dr. - ay permits )/ (�2- <br /> ADDRESS: <br /> 3-5 ' may, county,town CSM: Y✓ T f�f e +�ae, ,/ ' . anitary permits ?��� <br /> LO SUBWISION BLOCK/LOT <br /> Lot.I (Public,private) 3 p_ tr"A„(� 6 <br /> PROPOSED PROJECT INFORMATION IEW <br /> PROJECT DESCRIPTION. <br /> athile(Ct Yew single calmly lint) ` t-POf eBul l ❑ Zoning DV‘t <br /> his project is a new building or structure. <br /> A❑ Permitted use? <br /> ❑This project is an addition/alteration to an existing building or structure. V <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [$EPTIC }L3� �/1��1 D I (�/existing) <br /> HEIGHT IN FEET: ( <br /> NUMBER OF STORIES: (Not in� ng bassemen� <br /> . -t- 1`7 (jam ❑ Wetlan (,F / <br /> 1 Shor attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 0111 (� -51,Ft" C�, n�ij` 4 TOTAL SQUARE FOOTAGE: +, (slopes,disturbance, <br /> 2ND FLOOR:0 3RD FLOOR: `'�' 0�l["� <br /> filling/access) <br /> ❑ Revi 'on Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► -► ♦ ♦ t7©� and O e options. <br /> (Please round to nearest dollar) 350, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? :Yes 4o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? es EKo Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? I2 es 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 26o QDon't know <br /> 7. Is this to correct a violation?.. ❑Yes ❑No Nit <br /> 714...fie <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —P. -+ <br />