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&-71/7 DC&c—*eif—t
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<br /> . ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#
<br /> PROPERTY OWNER INFORMATION CUSTO TO PROVIDE
<br /> OWNER NAME Qf�
<br /> R-es /-�ry •■ oning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) / Gus' r► S/OP'�
<br /> /0,Z E Ai 14 A2 . Cot'm� -Ce-ys�w 35- Variance Restriction;CSM
<br /> r.� k.Lvrt d� � �' .S Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL AD ESS
<br /> or-SSW , ,V-c ws - Go 4 ❑ Si e Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions
<br /> AGENT NAME r\ CONTRACTOR NAME
<br /> P.e[ r o vfc i3rC4.._ K. p S e Plan including location
<br /> AGENT ADDRESS / CONTRACTOR ADDRESS o/ • well/septic
<br /> (City,State,Zip) (City,State,Zip) 1 ❑ybacks
<br /> a t/� c- ; t vs 5-31-2-5 L �/ u'r
<br /> PHONE PHONE / ❑ Site Plan approval from
<br /> G 6S -S-77-S�G ( applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> us- 1/1-4�'fG�� a- �#r ' ❑ F oor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/)
<br /> ❑ PARENT PARCEL NUMBER: CURRENT ZONING: , levation of property
<br /> c,7►z-Zz�l
<br /> PARCEL — /GGS Rif-3
<br /> ontage drawn to scale.
<br /> NUMBER c-
<br /> TO//NSHIP: SECTION: • rlVeWa ermits
<br /> lDRESS !1l4 !� '/<: /�/1 ) '/<'/.: S/=- __(sate,county,town)
<br /> ADDRESS: Q Z
<br /> 3�e.V `= /9k R ; ❑ .nitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT
<br /> (public,private)
<br /> 0 2-2-
<br /> PROPOSED PROJECT INFORMATION - `
<br /> PROJECT DESCRIPTION: °`<` z '
<br /> Sf R i-.26.r :c l�
<br /> /®.This project is a new building or structure.
<br /> ❑This project is an addition/alteration to an existing building or structure.
<br /> SANITARY SERVICE: PERMIT NUMBER: `e e °° "
<br /> ❑SEWER I SEPTIC4M t '
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) I/ a S ";3 `
<br /> AREA TO NEAREST SQUARE FOOT: I ,�- ;
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porch:-
<br /> Z
<br /> BASEMENT: 1ST FLOOR: !� `1 ° ° � ° _
<br /> Z 0 I J 2 S +, TOTAL SQUARE FOOTAGE: e s' �°` 4�
<br /> 2ND FLOOR: 3RD FLOOR: `J O F � ;1
<br /> .„ ,,,, ,,,,,,,,a,,,,i,,,,,,,,,„..,„,,
<br /> ESTIMATED CONSTRUCTION COST: $ n �� 1 -
<br /> (Please round to nearest dollar) '♦ --► -► ♦ --► ♦ ,� .,• , rf
<br /> 6„.„&,...0
<br /> /
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond • lake? tid Yes ❑No LI Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes U No ❑Don't know
<br /> 3. Have you talked with the township about your project and are the in agreement? ❑Yes ®No
<br /> 4. Has there been a zoning permit issued for this property in the --ast 5 years? ®Yes ❑No
<br /> 5. Is this project associated with a rezone/CUP/variance(petiti' /appeal# ) (leave blank if none)
<br /> 6. Is a location survey required? (see reverse) CI Yes ❑No ®Don't know
<br /> 7. Is this to correct a violation? ❑Yes N No
<br /> (_ 5 (9if - 3 7 3 a i�/ 37 APPLICATION MUST BE SIGNED
<br /> 545-112(4/08) / (Q (Continue on Back) ■ --► —►
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