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r >, <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVI �/ <br /> � �� Zoning Status;CUP; <br /> OWNER aESS (Num' bey,S1 eet,City,State,Zip) 77"C Deed Restriction; CSM 2 1& <br /> S �5 LoU)l K� G°aorrl W/ ��,��7 Variance(# ) <br /> HOME PHONE CELL PHONE E AIL ADDRESS <br /> ICJ , '119* .7 (�O9-9Y ' 5 6 75 '� R', (S 1 d B '� mr,,/.(c , l Site Plan drawn to sc� <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions v <br /> AGENT NAME CONTRACTOR NAME <br /> 5k',It 5gvv1J X Site Plan '.cluding locatio <br /> AGENT ADDRESS CONTRACTOR ADDRESS of -• <br /> (City,State,Zip) (City,State,Zip) j Setbacks ��3 �� �� <br /> PHONE PHONE OSite Plan approval from <br /> applicable township. <br /> E-MAI 'DRESS E-MAIL ADD: SS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of ro ert <br /> PARENTL PARCEL NUMBER: CURRENT O I G: ACREAGE: P P Y <br /> ❑ NUMBER 0494 • .;, -.) ': •-_ •2t', frontage drawn to scat <br /> TOWNSHIP: SECTION: <br /> �/,'e 2 I 1/4: 1/41/4: Driveway permi = <br /> ADDRESS: (state,county, o' n) <br /> 5��5 L OUIC/C 7Z� %I.Sanitary .�- <br /> CSM:4^ 7 LOT SUBDIVISION BLOCK/LOT <br /> S (public,private <br /> PROPOSED PROJECT INFORMATION �i',.,4 9 r_PROJECT DESCRIPTION: / , <br /> This project is new building o structure. f' '. ' <br /> This project is an eration to an existing building or structure. '! � , <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> �Rltl'�, �� , <br /> SEWER SEPTIC t1 ° <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) A etiandifinan-4-:,,-, .- A <br /> AREA TO NEAREST SQUARE FOOT: ✓ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) :_ <br /> BASEMENT: 1ST FLOOR: � �� ��� �, y�(,-,q,:,"!* <br /> / 0 j TOTAL SQUARE FOOTAGE: • � disturbance, /"of <br /> 2ND FLOOR: 3RD FLOOR: �� l I � �� <br /> V i ;ESTIMATED CONSTRUCTION COST: r� :18(::::._, ,, , ;;'11,::-.i.,. Ll <br /> (Please round to nearest dollar) •♦ ♦ ♦ 'i ♦ ♦ p(�a� ' $41 s y <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? El Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑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/CU- - ■ - � •,� # ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse ❑Yes. El No ❑Don't know <br /> 7. Is this to correct a violation? �-- ❑Yes ❑No <br /> $■ / F2 2 t AST BE <br /> (Continue APPLIC on TION BacMUk) ♦ -►SIGNED <br /> 545-112(4/08) <br />