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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER AME <br /> f, '�" LA) I I.c <br /> ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Stkeet,City,State,Zip) Deed Restriction;CSM <br /> CO S "_ ‘SC,i)r■S tic‘ Variance(# ) <br /> Fi.z5a PHONE CELL PHONE E-MAIL ADDRESS <br /> 0 0, • SC5 c.S'u Yn ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT N�j CONTRACTOR NAME <br /> ern <br /> `� El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE <br /> 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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: El Elevation of property <br /> ❑ PARCEL �^ ��// frontage drawn to scale. <br /> NUMBER 057/ft) L�(S dv �J`/�X g <br /> TOWNSHIP: SECTION: <br /> )(,0,-, k,'.- k 3 0 1/4: -1/41/4: ❑ Driveway permits <br /> ADDRESS: <br /> Vg ,c (state,county,town) <br /> Vo v n ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION REVIEW <br /> PR CT DESCRIPTION f <br /> DCA-Q:l </ e� ��t ' <br /> ❑This project is a new building or structure. <br /> Use? <br /> his project is an addition alteratio an existing building or structure. <br /> SANITARY SERVICE: <br /> PERMIT NUMBER: <br /> Q�ura re <br /> f SEWER PTIC new <br /> rxC <br /> HEIGHT IN FE T:, NUMBER OF STORIES: (Not including basement) I A'' <br /> X% M "k <br /> $1E0 €?( pl Mein) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) E <br /> BASEMENT: 1ST FLOOR: ° ° <br /> &C7.(� � 4, TOTAL SQUARE FOOTAGE: 4, T az1. ce, <br /> 2ND FLOOR: c <br /> 3RD FLOOR: 55 �°,` � ,: <br /> 0207'"s . 1/ <br /> ESTIMATED CONSTRUCTION COST: W `' <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ —► $ 600.n �© �d '' <br /> tJ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes JRNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? DYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes "No <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) Dyes ' No ❑Don't know <br /> 7. Is this to correct a violation? Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aios) (Continue on Back) ■ -♦ <br />