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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME �'� <br /> 1.v i G 30 Ai N t:U I l L IXkzsling Status;CUP; <br /> / OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 9530 ���Ck 3ERizy R L_r cIcLM1Zt1� 53s/5 Variance(# ) <br /> ry HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 61)e-35 e-8q 1 6pil-3583 8 I CFWIG .owl)r)/LLE6&AADPAk,CoN 'ePlandrawntoscale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> AA,6 BON A Ell ILA-£ ite Plan including location <br /> AGENT ADDRESS <br /> /. CONTRACTOR ADDRESS of well/septic <br /> 1530 8�4 dc.ar1z ry RD <br /> (City,State Zip) (City,State,Zip) tbacks <br /> ,13Lr9Cl< I=W12T4 1)J1 535 G <br /> PHONE PHONE ❑Site PI pproval from <br /> 6 Ob- 35-8 -8,45 ) ap ' bI ownship. <br /> E-MAIL ADDRESS E-MAILADDRESS PAK.0 M <br /> C'R19iC.a 0N,Al Ell Ltd @gi oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) le vation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ❑NUMBER (A06., —Q g 14 - z 5, j frontage drawn to scale. <br /> 6 <br /> TOWNSHIP: SE S101 <br /> ?own) OF ��►1rICIC tt4RT14 `S y4: NJ i '/4% „ / ❑Drivew rmits <br /> ADDRESS: (St CO ty,town) <br /> 95 ,o BLA(lc 0KR Tat z BUaCK e14R?N W( 53�is <br /> anitary permit x___ <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) p y, <br /> PROPOSED PROJECT INFORMATION ST FF REVIEW <br /> PROJECT DESCRIPTION: PO /n 6-0 in `' onin District <br /> This project is a new building or structure. ermitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. r� <br /> SANITARY SERVICE: PERMIT NUMBER: I_1 Rural Address <br /> EWER rEPTIC NA (ne ,i1�•,_ <br /> HEIGHT IN FEET: 1 //_, NUMBER OF STORIES: (Not including basement) <br /> �/ / w e -nd/Flood•.:in/ <br /> Shorela .• - -chment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> • Erosio ontr• •ermit <br /> BASEMENT: 1ST FLOOR: p <br /> I -7 7 ,, TOTAL SQUARE FOOTAGE: , (slopes, •'_ •rbance, <br /> 2ND FLOOR: 3RD FLOOR: �j flllln• <br /> 17 Z ■ Review Loca on Surv- <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q� i and available o• ions. <br /> (Please round to nearest dollar) $ / S,� <br /> ■ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres 10No ['Don't kn• <5.'2. Is there a wetland or floodplain on or near the property? Yes No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ?[ Yes ❑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) NYes Elo ['Don't know <br /> 7. Is this to correct a violation? Elves lao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -4 <br /> 545-112(4/08) <br />