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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 /> -rA.0l,4,041' ' nin <br /> og Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> /\,' X102 �'Mt -r iZD • Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Ian drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> T5Vi l °L✓ir Sf I e Plan including location <br /> \.,/AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE / W' S77— ❑ Siteat royal from <br /> 619 ,1.22 . 64-G appli township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> .Aav <2r1AG kukyv�}, or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) • <br /> PARENT PARCEL NUMBER: CUR ENT ZONING: ACREAGE: Elev u�ofproperty <br /> ❑PARCEL /-4— )- 7.4- j 61 ntage drawn to scale. <br /> NUMBER O.1 0 I\a- 97CfQ Q / <br /> TOWNSHIP: SECTION: r <br /> V � <br /> eiVAC -C f 1/4: N 1/41/4: S ? ❑ Drive y rmits 1 <br /> ADDRE /1 <br /> F' (st , unty,town) -1,T <br /> �? ' Mc-(. �_ l anita .- .ts <br /> CSM: LOT i SUBDIVISION BLOCK/LOT (public <br /> C-) f <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> n isi <br /> -S G� :7 Lt�f te= pug S K kTatE-K) ? w.vc M , rct <br /> / <br /> . ❑This project is a new building or structure. rmitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Urat 1••},,e�ss <br /> EWER ' EPTIC (ne -xisttng'Ir <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <.' , E <br /> 2 .e.land/ •�.r e t '1 <br /> AREA TO NEAREST SQUARE FOOT: �" / <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) o Nits r�` YCar <br /> BASEMENT: 1ST FLOOR: rosionControl perm y <br /> TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 1 4, fitting/access) WD,O) <br /> 110T- —�+ s evtew Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ and available options. <br /> round to nearest dollar) $ 2�.1., (v 5`--f, J <br /> / / 140 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes fNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Efres No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres 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? Efres No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />