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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O AME <br /> A k/f�/i �� �'YLey✓ ❑Zoning Status; CUP; <br /> 0 A ADDRESS umber,$treat,city,sta�zip '� N �� Deed Restriction; CSM ) <br /> 6 / /_11 !/" V'If'� Variance # <br /> HOME PH NE CELL 'HONE E-MAILADDRESS <br /> ' 5 0% �/ ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL / _ cX /62 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> _(L '/4: '/4'/4: ❑Driveway permits <br /> / , ' (state,county,town) <br /> AD <br /> AD RESS: <br /> 7/5( 4 .T1 � .-e'—e, ❑Sanitary permits <br /> CSM: OT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> /lam �- ,-c.ry� 5 A -ems 60 '1 / yd .•ntng of 1 , <br /> . )This project is a ng building or structure. Li Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. , <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> FIEVVER QEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> Z..2.2 / © Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Stt?fBl #) attaIRi4[�} <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) r-1 ,toil ___.„ `,- <br /> BASEMENT: 1ST FLOOR: TOTAL SQUARE FOOTAGE: s: <br /> 4, � � � � t�ls�urbe� , <br /> ,±filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> C Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: q O lj— and available options, <br /> (Please round to nearest dollar) ♦ ♦ -► <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Peso ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? jaes ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 12Kes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies _1■1I4o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) Oyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ —► —► <br /> 545-1120/08) <br />