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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME CUSTOMER TO PROVIDE <br /> e evvkt 1h s-}-e_04) ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> �a SAS �4, ,.�I 16) Deed Restriction; CSM <br /> HOME PHONE CELL PHONE ariance(# ) <br /> E-MAIL E-MAILADDRESS <br /> - 13-01 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / <br /> CONTRACTOR NAME <br /> (,O�acS 1(, t.L&c- -yl4 Hbmis ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 64 b I A) Gev)- vy 'V-e. <br /> (City,State,Zip) (City,State,Zip) <br /> ❑ Setbacks <br /> CAbu 04-Q-t U I 5-(3 <br /> PHONE <br /> PHONE ❑ Site Plan approval from <br /> $S7) clq 5-0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> /co _ cx_1716 -wa.L.Lvta4 e , cow) ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> El PARCEL O D �a� �d3 O - i frontage drawn to scale. <br /> NUMBER 0_ S13 <br /> TOWNSHIP: SECTION: <br /> at-e- %: %I A: ❑ Driveway permits <br /> ADDRESS: -r' (state,county,town) <br /> Co-f50 v ‘A- ❑ Sanitary LOT SUBDIVISION BLOCK/LOT ry permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: �e <br /> �x�0 iv. Ynuv�� oo ing <br /> 9 <br /> • This project is a new building or structure. ji- <br /> � ed use, <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: CI Rural <br /> flew <br /> nSEWER SEPTIC ��` k <br /> HEIGHT IN FEET: YYY "' NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> �a �tt <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 1 <br /> BASEMENT: 1ST FLOOR: El" OIItrOET[i1t%1 t.0 ,, TOTAL SQUARE FOOTAGE: j ?,e +1f*u, t ce, A. <br /> 2ND FLOOR: 3RD FLOOR: <br /> fl $ <br /> � �0 <br /> ESTIMATED CONSTRUCTION COST: tva � <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? ❑Yes ❑No ❑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? ID 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/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -■ -► <br />