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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> OWNNBR N E
<br /> -.ffi?"J4te7eLO rl./r
<br /> v Zoning Status;CUP;
<br /> OWN ADDRESS ( umber,Stre city,Stet",Zip) ni Deed Restrict}pn;CSM
<br /> �0d /(4-1/V%S >f/'4- To( / /v/etr�d, Variance(# 7670 )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> a 'l`077 , t, • Avi f G.. ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> 277 1/i /v'` .
<br /> (City,State,Zip) (City�,,state,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> 2 __l iF7 applicable township:
<br /> E-MAIL ADDRESS E-MA^IlLADD�ESS
<br /> •©/A/7 -COG.-ii-pe-yi• , M Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevtif
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG Elevation oproperty
<br /> ❑ PARCEL /6V- �7-0/0 Jr P-zf frontage drawn to scale.
<br /> NUMBER r p z/�' (/
<br /> TOWNSHIP: SECTION:
<br /> , 'i'J. / ' ' ,x t ❑ Driveway permits
<br /> ADII Iss: . <. (state,county,town)
<br /> 7-057 i?"-YH, boa`—" ❑ Sanitary permits
<br /> CSM: OT SUBDMSION BLOCK/LOT (public,private)
<br /> Z-;L
<br /> PROPOSED PROJECT INFORMATION Fli7''''z ,�-
<br /> PROD C ESCR-TION: x r
<br /> / .cam E, 7;3,
<br /> " fl� -„,, 4 "
<br /> i i /l7 ,ar—, / � 171� t ,
<br /> • TN This project i a new building or structure. � irr ,
<br /> ❑This project is an addition/alteration to an existing building or structure. t`- _ :; _,
<br /> '
<br /> SANITARY SERVICE: - r �■®� �a
<br /> ❑SEWER SEPTIC n zai a
<br /> HEIGHT IN FEET: NUMBER OF STORI S: (Not including basement) t ' a.
<br /> 1' l °t' r , ,ft=-
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) z � r -,°
<br /> �s �„, r
<br /> a r:
<br /> BASEMENT: 1ST FLOOR: s q ;
<br /> / _ //7.5v . ,, TOTAL SQUARE FOOTAGE: ,, Y,,,±,
<br /> Y/ SI ill 1'`e � '„_„1.-,„-. ._.3
<br /> 2ND FLOOR: 3RD FLOOR: z ,`max` '
<br /> ESTIMATED CONSTRUCTION COST: �y,� �J Mt , g,
<br /> (Please round to nearest dollar) --► ♦ --► ♦ ♦ ♦ $ 2_,F Q(!i r
<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 ❑No $1 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 1No
<br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) e blank if none)
<br /> 6. Is a location survey required? (see reverse) ;�% es %lI o ❑Don't know
<br /> 7. Is this to correct a violation? a Yes , No
<br /> ` 7 APPLICATION MUST BE SIGNED
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<br /> ,--,2, u ��� � �� (Continue on Back) ♦ —►
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