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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNV3 NAME CUSTOMER TO PROVIDE <br /> ~— [3 Zoning Status; CUP; <br /> O'E"JJCR ADDfiESS IFlumber,Street,C' ,State,Zip) <br /> 2 Ems? 7 S �'t2 4/7 �, Deed Restriction;CSM <br /> ' _ PHONE .pG _ _/✓� GU.� S3 �t Variance(# ) <br /> ,J( pt( 41e1 V6� k D 4,A s+ 9 l E ri- -H� SS • '' <br /> 41501-C 4,41 ❑Site Plan drawn to scale <br /> AGENT INFORMATION 1 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.2ip;. (City,State,Zip) ❑Setbacks <br /> PHONE PHONE Site Plan a <br /> ❑ approval from <br /> applicable township. <br /> E-VA!LADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PI RTY/LOCATION INFORMAT ION (http:l/accessdane.co.dane.wl.usl) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CU RENT ZONING: ACREAGE: <br /> O NUMBER O 0©1—o'/ M /)?—/ / /4 / /3 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> S,Ql?y10 f4,R,el( 1�4: 1/44: ❑Driveway permits <br /> ADDRESS: , ! (state,county,town) <br /> CSM ) -5 6/LOT %/r oa` SUBDIVISION BLOCK/LOT 3 ct ❑Sanitary permits <br /> 1? (public,private) <br /> PROPOSED PROJECT INFORMATION STS X400: <br /> PROD EIPTION: <br /> ---+ c4; es U 2aningDistnpt,_ <br /> ❑This project is a new building or structure. © Permitted°:Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: © Rural Addr• <br /> EWER 1�tiEPTIC NUMBER OF STORIES; (Not including basement) ❑ � 8nd/Floodpl <br /> 1 Storeland (attachment). <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: O <br /> : tiisji3aCat�brat 1 <br /> J( 1 TOTAL SQUARE FOOTAGE: 1 (SIPPM 4OStEltb,fanCe,, . <br /> filling/ages$) <br /> 2ND FLOOR 3RD FLOOR (� <br /> --- - <br /> C)-1) uX Review .apatiOn Survey <br /> ESTIMATED CONSTRUCTION COST; Q arttiavai)ablO 01400s•-. <br /> (P'easc rcu:'d to nearest dollar) -r -� $ ���1�" <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes INNo DDon't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IINI o [ Don't know <br /> 3. Have you talked with the township about your project and are they in agreement?_ [Yes U o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 110 <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) Lives zi,,,,o aon't know <br /> 7. Is this to correct a violation? ❑Yes :4 o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -i -i <br /> 5t:r-12('-l)l) <br />