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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> \TOSe, • lGW4. <4. •p • <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> if . r fit` 5 r Deed Restriction; CSM <br /> HOME PHONE `�'b-, Variance(# ) <br /> CELL PHONE E-MAIL ADDRESS <br /> i0.9-. 3 - 53 170 J v Z°c Kg , 'kr€l? , PIE 1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION <br /> AGENT NAME and includes dimensions <br /> CONTRACTOR NAME <br /> AGENT ADDRESS �a v r ' 1 A III Site Plan including location <br /> CONTRACTOR AL,A .-ESS of well/septic <br /> (City,State,Zip) l� r�D j 1 < 1 <br /> (City,State,Zip) ❑ Setbacks <br /> PHONE o A h Lc/ rr <br /> PHONE � El ii v <br /> Site Pl-,1 a . rom <br /> E-MAILADDRESS "e)-J"]' — 5550 applic /• le n- ip. <br /> E-MAIL ADDRESS <br /> ' 1 Floor plans to scale <br /> 1 <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) AI <br /> ❑ PARENT - CURRENT ZONING• 1 Elevation of property <br /> PARCEL - <br /> NUMBER # J , / #, _ * 4 �� .-3 frontage drawn to scale. rSiL <br /> TOWNSHIP: SECTION: <br /> -�. .r ,, <br /> 1/4: •/Y/a: ` Driveway permits <br /> ADDRESS: (state,county,town) <br /> Milli 2/'LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: -, #tf# VE <br /> I [ . /. * <br /> 14�� <br /> This project is a new building or structure. 1 t d 1 <br /> II <br /> �t�use <br /> This project is an addition/alteration to an existing building or structure. , #r t 49 <br /> PERMIT NUMBER: PI ur Address <br /> • <br /> (new/existing) , <br /> NUMBER OF STORIES: (Not including basement) ,. <br /> Elmer if• ,••t ni , <br /> AREA TO NEAREST SQUARE FOOT: ° � t <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) I 1. .m it <br /> 1ST FLOOR: �..= s <br /> 1 j TOTAL SQUARE FOOTAGE + ' ° .'' ® yr, r<s s <br /> 2ND FLOOR: 3RD FLOOR: • / = `' . tra w° ' <br /> A 1 A Fc I ' .- : g -1-;i-ESTIMATED CONSTRUCTION COST: " <br /> (Please round to nearest dollar) ♦ '-► -••► ♦ -♦ -•► :ii . •.goao <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? <br /> ❑Yes r o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes lin o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ►� <br /> �/No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# <br /> (leave blank if none) <br /> 6. Is a location survey required? (see reverse) <br /> Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? <br /> es Rlo;z <br /> iip.. \\\ <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aios) (Continue on Back) <br />