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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME < �, a dk d}t- <br /> A :i r'1 a .7...) • eft- e ,-Jer CSC 4 G tt 142lti,i i)' J/i/ // IPtSI ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 161 0 N Gro v' skeet /)1w n t { 1&b, w- s 3r'7,2 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDREg S <br /> 60g- I Z-6W t/ 0R=712 .6SS 9 r o t &tin P ' 2J— ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ 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/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL OS0G 'c.972-aco0,ci .41 _ Ex- d q, to frontage drawn to scale. <br /> NU <br /> TOWNSHIP: SECTION: <br /> n2 �p '27 1/4: 1/41/4. ❑ Driveway permits <br /> h' / (state,county,town) <br /> ADDRESS: <br /> Jam) E cl.` !4 w y ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Ok — X W SkD`ra- to U\-S I ing District`. <br /> . This project is a new building or structure. El Permitted Use? %-! <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Addre <br /> E1SEWER SEPTIC (new/exiStin9} <br /> HEIGHT IN FEET: \ /^ NUMBER OF STORIES: (Not including basement) � � Y <br /> r attach , <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: EFt}S10i1 # <br /> TOTAL SQUARE FOOTAGE: (�,dis�ance, <br /> Ihnacs) �' <br /> 2ND FLOOR: 3RD FLOOR: y <br /> /C9oxa (. <br /> ESTIMATED CONSTRUCTION COST: $ ica7 gam a 'S able. i iS. <br /> -. -. --► " <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 Ire o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes !9 o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes re o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes iffp o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes rill ❑Don't know <br /> 7. Is this to correct a violption? ❑Yes No <br /> ,C UN 5 APPLICATION MUST BE SIGNED <br /> �QC 0� (� �.G'" (Continue on Back) -*Ioeft 545-112(4/08) , <br /> ,SS p�� vad .,ED( �� � � l�'I <br /> ,S5 4v' <br />