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ZONING PERMIT APPLICATION www.countyofdane.com <br />SUPPLEMENT to Web -App # <br />❑Yes <br />PROPERTY OWNER INFORMATION <br />CUSTOMER TO PROVIDE <br />OWNER NAME <br />❑Yes <br />Ca. �Nhlh:a-mS <br />❑ Zoning Status; CUP; <br />Deed Restriction; CSM <br />OWNER ADDRESS (Number, Street, City, State, Zip) <br />IS -3 ` `&3-7/3 <br />Imo- C tl I WT 5 <br />variance (# ) <br />HOME PHONE CELL PHONEE-MAILADDRESS <br />3q pC ,��, /'coin <br />- -2142 <br />EIMI'5 <br />❑Site Plan drawn to scale <br />AGENT INFORWATION <br />CONTRACTOR INFORMATION <br />and includes dimensions <br />AGENT NAME <br />CONTRACTOR NAME <br />i n Kne r' <br />� I ` -Dee4 &n <br />Site Plan including location <br />of well/septic <br />❑ Setbacks <br />AGENT ADDRESS \160 <br />2110 Mita hf i LuAer l4' r. AI <br />CONTRACTOR ADDRESS J <br />(City, State, Zip) <br />(City, State, Zip) I <br />K&AAsicn, S3"1 13 <br />Al -7- 5550-2- <br />❑Site Plan approval from <br />PHONE <br />PHONE -GU <br />D8-Z1o6-9682- <br />0g--112-- I <br />applicable township. <br />❑ Floor plans to scale <br />E-MAILADDRESS L+pµn}Np q�,Cp <br />E-MAILADDRESS <br />�, . QFC <br />PROPERTY/LOCATION INFORMATION (http://accessdano.co.dano.wi.us/) <br />PARENTPARCEL NUMBER: CURRENTZO-/NIING: ACREAGE: <br />632 '10 R[-• <br />❑ Elevation of property <br />frontage drawn to scale. <br />-352-16PARCEL <br />-]NUMBER V�, o -ILA <br />permits <br />TOWNSHIP: <br />SECTION: <br />'/<: 1/41/4.❑Driveway <br />�` <br />(state, county, town) <br />ADDRESS: <br />❑ Sanitary permits <br />(public, private) <br />CSM: LOT SUBDIVISION BLOCK/LOT <br />57 <br />PROPOSED PROJECT INFORMATION <br />3,AF+ISR <br />PROJECT DESCRIPTION: <br />-4. <br />This project is a new building or structure. <br />This project is an addition/alteration to an existing building or structure. <br />s" <br />SANITARY SERVICE: <br />PERMIT NUMBER: <br />EWER EPTIC <br />r ' a' <br />HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br />AREA TO NEAREST SQUARE FOOT:. <br />' <br />(Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br />??" <br />BASEMENT: <br />G00 <br />1ST FLOOR: <br />TOTAL SQUARE FOOTAGE: 1 <br />2ND FLOOR: <br />3RD FLOOR: <br />N <br />y. <br />ESTIMATED CONSTRUCTION COST: <br />♦ ♦ ♦ ♦ <br />(Please round to nearest dollar) <br />' <br />1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ........... <br />2. Is there a wetland or floodplain on or near the property? ............................................ <br />3. Have you talked with the township about your project and are they in agreement? .... <br />4. Has there been a zoning permit issued for this property in the past 5 years? ............. <br />5. Is this project associated with a rezone/CUP/variance (petition/appeal # ) <br />6. Is a location survey required? (see reverse).............................................................. <br />7. Is this to correct a violation?....................................................................................... <br />545-112 (aioe) <br />❑Yes <br />no [-]Don't know <br />❑Yes <br />�No ❑Don't know <br />❑Yes <br />❑No <br />❑Yes <br />Ad <br />(leave blank if none) <br />❑Yes <br />[]No ❑Don't know <br />[-]Yes <br />XNo <br />APPLICATION MUST BE SIGNED <br />(Continue on Back) -i -► -► <br />