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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OER NAM/ / <br /> ow ERADDR � e ss e <br /> KZoning Status; CUP; /� / <br /> ADDRESS (Nu ber,Street,City,State,Zip) Deed Restriction; CSM / '6? <br /> ST77 ( 4 e � ec' �� w�535," <br /> HOME PHONE IP S �P1�� '� Variance(# ) <br /> CELL PHONE E-MAIL ADDSS <br /> ', 51 to 5 - . •µit, / , E o .-t ❑ Site Plan ra to scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includ dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site PI n i luding loc tion <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/ <br /> 3 0 3C' <br /> (City,State,Zip) (City,State,Zip) Z Setbacks <br /> PHONE PHONE X Site Plana pro al from A 7 <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> rd Floor plans to scale Q/ <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ��1 Elevation of in %erty / <br /> ❑ NUMBER t�gD 1 ./‘Y9)JQ/ 1( ( /. 7 ( frontage drawn to scale. ✓ <br /> TOWNSHIP: SEC_ IO : <br /> L' X... 1-- J b 1/: ,j %1/: ,Sg 1k Driveway permi Ait/4-- <br /> ADDRESS: (state, county own) <br /> gS.•' .ry permits A (/,� <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> g4 G 6t publ'.,private) '�JUfi <br /> PROPOSED PROJECT INFORMATION r F REVIEW <br /> PROJECT DESCRIPTION: 4 T <br /> .,4‘ or .- i e e,,Q ic_;i) c-tr This project a new building or -tructure. �PerMittecd Use? <br /> ❑This project is an a..i i. - eration to an existing building or structure. „4,444-.F45. �4 <br /> SANITARY SERVICE: .m <br /> PERMIT NUMBER: <br /> SEWER (SEPTIC th„ ;ems) <br /> HEIGHT IN FEE l `l NUMBER OF STORIES: (Not including basement) <br /> + , „g .•a' Bin/ / <br /> AREA TO NEAREST SQUARE FOOT: <br /> / ,';'-.7f .':- • chmeI) (/ <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) , r ` <br /> BASEMENT: 1ST FLOOR) ° <br /> /��O 4, TOTAL SQUARE FOOTAGE: j ( ,s s- * ce, ro <br /> 2ND FLOOR: 3RD FLOOR: P”''' �' 4 <br /> x <br /> id ESTIMATED CONSTRUCTION COST: � �� �v����63' <br /> � <br /> (Please dollar) -► --► ♦ ♦ -► $ 02 41 6D0rff - Arid r l l' ltd <br /> Please round to nearest dollar v � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No El 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? ❑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 /> i `' APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ —► <br />