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ZONING PERMIT AF'PLIC.AT1ON www.00untyofdane.00m :. <br /> PROPERTY OWNER INFORMATION OFFICE USE ONLY <br /> OWNER NAME! <br /> :g 3-6141450 N f • Zoning District <br /> OWNERADDRESS (Number,Street,City,State,Zip) <br /> 30 Z(4 S4M M l L S D. 5T611644-1-6K, (11- 5358q • Permitted Use? <br /> PHONE E-MAIL ADDRESS <br /> 0 —873-Ltq 1(a TI(lie erne. '' Life t,tiire,yid- • zoning Status;C_ P; <br /> AGENT INFORMATION CONTRACTOR INFORMATION Deed Restrictio CSM <br /> AGENT NAME CONTRACTOR NAME Variance(# ) <br /> T A GE i-}AASon) 1 llr_WRY CbA15?2 i C i7oAl <br /> AGENT ADDRESS CONTRACTOR ADDRESS <br /> Z <br /> •3S4 141,10/4 +eC. g5 V!EuM 12P. and includes drawn scale <br /> and includes di '-nsions <br /> (City,State,Zip) (City,State,Zip) r <br /> c kc-.NTV ( <br /> ,J1 03 535gq STOUG T0A) �T 5353 Site Plan includi location• <br /> PHONE PHONE <br /> ( 0S- 873-')57`7 100a-- 873-1-}og3 of well/septic <br /> E-MAIL ADDRESS E-MAIL ADDRESS • Setbacks <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) • Site Plan appro 4 I from <br /> PARENT• PARCEL PARCEL NUMBER: ZONING: �7 ACREAGE: 7 applicable town Ip. <br /> NUMBER 0511- 191-8800-3 A G- 5 u5Z <br /> TOWNSHIP:1� SECTION: <br /> unI KI RK 1/4: ,/4,/: • Rural Address <br /> ADDRESS: (new/existing) <br /> 30Zq SAM M t t,e5 I-P., TOM 6 t-f TbIJ, ln)! 535N • Floor plans to s 'le <br /> CSM: p LOT SUBDIVISION BLOCK/LOT <br /> o I sq I • Elevation of pro rty <br /> PROPOSED PROJECT INFORMATION frontage drawn t scale. <br /> PROJECT DESCRIPTION: <br /> C—tkRAC-C, �jf} f Boom F' CL-05e7 t • Driveway permit <br /> . • This project is a new building or structure. (state,county,to n) <br /> COI is project is an addition/alteration to an existing building or structure. <br /> •SANITARY SERVICE: PERMIT NUMBER: Sanitary permits • <br /> • •SEWER 0-SEPTIC (public,private) <br /> HEIGHT IN FEET i S / NUMBER OF STORIES: (Not including basement) wetland/Floodpl.in/ <br /> Shoreland (atta ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) • ErosionControl rmit <br /> BASEMENT: 1ST FLOOR: <br /> 3 ( (,2-14/11903 j TOTAL SQUARE FOOTAGE: j (slopes,disturb ce, <br /> 2ND FLOOR: 3RD FLOOR: CU IZ(2E74T: P RvPGS E'P: <br /> filling/access) <br /> ''II l k, <br /> `T 2'l kll} 2,069 / Z,6 ?3 • Review Location.Survey <br /> ESTIMATED CONSTRUCTION COST --► -,► ♦ ♦ $ 1! b 72_ and available op tons. <br /> (Please round to nearest dollar) <br /> 1. Th Cercj T 51J t from a pond or lake? • Yes • No • Don't know <br /> 2. Th 1,11 I f if : -. / ',' , ,_ I I c- /? • Yes • No • Don't know <br /> 3. Ha • Yes • No <br /> 4. Ha� -f 1 in the past 5 years? • Yes • N <br /> 5. Th I( tii l� 1/4 (petition/appeal# ) (leave blank if none) i <br /> IO i , 4 : N� Sw, <br /> 6. Is, /,, l_ • Yes • 0 • Don't know <br /> 7. Is• NC • Yes •@ <br /> APPLICATION MUSIC;BE SIGNED <br /> (Continue on Back)r.-+ —+ — <br /> 545-112 • <br />