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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> ow R NAM CUSTOMER TO PROVIDE r OWNERADDRESS (Number,Street,Cit ,State,Zip) ❑ Zoning Status; CUP; <br /> r°\- �q Deed Restriction; CSM <br /> C GQ L,S 5 3 7 / ' variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> a� -- 1 y65 X33"- 0 SCE <br /> AGENT INFORMATION ❑ Site Plan drawn to scale <br /> CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Cif , Gt— CC lC ❑ Site Plan including location <br /> AGENT ADDRESS CONT CTOR AD ES Of well/septic <br /> 363 � ��� l�h�( Dunn <br /> (City,State,Zip) <br /> (city State,Zip) ❑ Setbacks <br /> .fide hton ( T-� �35 <br /> PHONE <br /> PHONE / ❑ Site Plan approval from <br /> b,6 So 1— 7� D applicable township. <br /> E-MAIL ADDRESS E-MAIL/ADDRESS <br /> 1 -` O 6 C �'�6X C/� ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> ❑ PARENT PARCEL NUMBER: CURB NT ZONING: ACREAGE: ❑ ElevatlOn Of property <br /> PARCEL D / _ r 7-P- -5 I <br /> NUMBER �/ ` o �j I I frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /: //: ❑ (Dsrtaivteewcaoy u permits <br /> nU n 1 <br /> ADDRESS: <br /> ti 7(g Nv r t Lit-1-e 01 a C 's°N" (�1_� <br /> CSM: LOT �' ❑ Sanitary permits <br /> SUBDIVISION BLOCK/LOT <br /> 1 m ,40(,.) v(2 (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PR`O`,,J�CT DESCRIPTION: ,+ .I�" , ,/, <br /> ❑This project is a new building or structure. <br /> 79_jci41-10r) <br /> This project is an addition/alteration to an existing building or structure. �% y` <br /> SANITARY SERVICE: PERMIT NUMBER: Rural <br /> /SEWER (SEPTIC y ' ;d / <br /> HEIGHT IN FEET:I b / NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: B <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> '� * o t('���: ,t ' <br /> D 1 TOTAL SQUARE FOOTAGE: j • +j i : * <br /> 2ND FLOOR: <br /> 3RD FLOOR: /1 O / � rl �� � <br /> ESTIMATED CONSTRUCTION COST: � �otBYV .;���� `' <br /> (Please round to nearest dollar <br /> -► ♦ ♦ -► ♦ ♦ $ 108 a93 aD � <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? ❑Yeso ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreementDYes 2No <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 arezone/CUP/variance(petition/appeal#,A�7 a 7 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes 2-No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑'No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aioa) (Continue on Back) ♦ ♦ ..► <br />