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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER ME C .TOMER TO PROVIDE <br /> C, C <br /> OWNER ADDRESS (N er,Street,City,State,Zip) ZO ing Status; CUP; <br /> 1 3 / /, -' e, 51-- )A M�J D e estriction; CSM <br /> HO PHONE E L PHON V r nce(# ) <br /> • $O 4 r 'O y. ��� E-MAIL ADDRESS <br /> AGENT V S.a Plan drawn to scale <br /> GENT INFORMATION <br /> CONTRACTOR INFORMATION <br /> d 'ncludes dimensions AGE NTNAM CONT ACTOR AME _U 17 4 ' " e G '�/' g v// to Plan including location <br /> n AG/44)r <br /> ADDRESS <br /> *3 ) CO NTRACTOR RESS <br /> 7H Ce-eA S7- 3 3 J E S'1 f well/septic <br /> (City,,Sta/te,ZAP) �/ (City,State,zip (/Ai ��� Setbacks <br /> PHONE <br /> PHO" ❑ <br /> g°50—_ 6 � / .e Plan royal from <br /> 7 d --O--‘6.5. C p ica township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARCEL PARCEL N E UR TZONI ACREAGE: Elevation of property 0 El NUMBER �� f" � � ( • frontage drawn Cale. <br /> TOWNSH P: SECT N: r <br /> '/a: <br /> N F %,%: rive permits .a.t <br /> —S,c A° its: (St ,county,town) <br /> CSM: LOT,/ SU j�,IVISION BLOCK/LOT Sanitary permits V r <br /> 7 .il/�j� � •ublic, private) ' �\ <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESC rtoN: / 'TAFF REVIEW Ill& ` ❑ •ning District <br /> his project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. ❑ Permitted Use? <br /> SANITARY SERVICE: PERMIT NUMBER: I/ (Rilral ddress <br /> EWER EPTIC /3 ^ C� i_ coa Lt (new/ isting) <br /> HEIGHT IN FEET: NUMB�jOF STORIES: (Not rincluding basement) <br /> 30 o'` ❑ Wetland/FI plain/ <br /> AREA TO NEAREST SQUARE FOOT: Shorel (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErOS10r1COn permit <br /> j t,/F �'� A36.0 j TOTAL SQUARE FOOTAGE: 4, (slopes, . turbance, <br /> 2ND FLOOR � �3RCD�FL000R:J / l I <br /> filling/ ccess) <br /> ESTIMATED �t 7/ ❑ Review Location Survey <br /> D CONSTRUCTION COST: /�j�� y (� <br /> (Please round to nearest dollar) '� '♦ ♦ —► ♦ I $ 5425 &CO and avail-• e options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 01'es <br /> qv ODon't know <br /> 2. Is there a wetland or floodplain on or near the property? Oyes Rio ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement? OY V o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? OY s r' o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (le a blank if one) <br /> 6. Is a location survey required? (see reverse) es ODon't know <br /> 7. Is this to correct a violation? Oyes o <br /> j_k <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aioe) � (Continue on Back) <br /> l <br />