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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER�M <br /> L in r ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> Z.V2/- ln L ZA b't fi, Variance(# ) <br /> HOME PHONE CELL PHONE -�/,, E-MAIL ADDRESS �y <br /> '"33-1-0 5 I TIC/ ..c-+�. 4 th e einq fl o`irt •Neill 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/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURB TZ ING' ACREAGE: <br /> El NUMBER �1I0--a- r 9 0Oa S �e� 's-1-. frontage drawn to scale. <br /> TOWNSHIP: SE ION: <br /> 1/J 1 �.�- 1/0: �'1f Y41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town)OS-3 CeC) <br /> CSM: LOT • UBDIVISION BLOCK/LOT E1 Sanitary permits <br /> �I (public,private) <br /> 1 <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: Ad <br /> . ❑This project is a new building or structure. i's, �1 0 usel 1.4Af, <br /> ❑This project is an addition/alteration to an existing buildin or structure. 3' <br /> Y .. <br /> RUl i�l> rem <br /> SANITARY SERVICE:SEWER EPTIC PERMIT NUMBER: n ) <br /> HEIGHT IN FEET: NUMBER OF RIES. including 9 basement) <br /> Shor ,. ( , nt) <br /> AREA TO NEAREST 4JARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) w ,c "�i <br /> BASEMENT: 1ST FLOOR: ' ; t <br /> TOTAL SQUARE FOOTAGE: 1 (slopes 3,`_ �"nce <br /> 4r ii3i .t <br /> 2ND FLOOR: 3RD FLOOR: 8 /i.., <br /> 1 <br /> ESTIMATED CONSTRUCTION COST: ^ d� . €.i# <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ 4 I O ^Q Q s 1'f „ p, $; , ' <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? ❑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 0 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -+ <br /> 545-112(4/08) <br />