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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 11 oning Status; CUP; <br /> OWNER ADDRESS umber,Street,Ci State,Zip) ` De d Restriction; CSM ) <br /> 2 l 2 e (o ` [ r./r� 'Porn f `J �Jh 141. V riance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> / <br /> A98.239, 0(0 .0 n - b i e 8 'C, r r. y t.Y". a Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> n1 G•t�, b c i-2 ���ti 4/1191/3 /ir/5 ite Plan including location <br /> A <br /> 7—: <br /> T ADDRESS CONTRACTOR ADD f well/septic <br /> 09= �Lfer r St �'. ,S7c, �nhe✓uW Dr . <br /> (City State,Zip) (City,State Zip) setbacks <br /> PHONE _ PHONE ❑ PI approval from <br /> ( 't7&e 2 3 S - / 8(c E:. c$ - S3 tf • 9A f3 ;ppli ble to ship. <br /> E-MAIL ADDRESS E-MAILADDRESS <br /> iM 6 Si ,ri 0I- 1, ( Z' Floor ans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: . Elevation of property <br /> PARCEL /� frontage dra to scale. <br /> UMBER 0 (o'234.` 1 3 d 111 L �3 t g <br /> TOWNSHIP: SECTI <br /> • N _ 1h: S E 1/41/4: ❑ Drivew permit <br /> ADDRESS: ���-/ (sta ,count own) <br /> '`2 C©/I,4(/(09 IIAf f�• BDIVISI4 y Lit. <br /> BLOCK/LOT E El Sanita permits <br /> 0 1, S I 0 I>^ publ' ,private) <br /> PROPOSED PROJECT INFORMATION R i , <br /> PROJECT DESCRIPTION: / i 4, <br /> -.---ie ei' <br /> . CgThis project is a new building or structure. - , ,,- .. <br /> ,,,,: 01r <br /> ❑This project is an addition Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 8°k °IC) x <br /> nSEWER EPTIC 1° ° '1;41 <br /> HEIGHT IN FEET: NUMBER OF STORIE . (Not including basement) I '' <br /> AREA TO NEAREST SQUARE FOOT: tlB *IV <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) [ , p <br /> BASEMENT: 1ST FLOOR: ,��;� � � s°� �� �� <br /> S� ,, TOTAL SQUARE FOOTAGE: + +€ k € • , <br /> ft)in,.,l <br /> 2ND FLOOR: 3RD FLOOR: /% " , <br /> ESTIMATED CONSTRUCTION COST: r � Review fiOIR�� �� <br /> (Please round to nearest dollar) ..+ "♦ ♦ ♦ ♦ ♦ 2 1, �f-8© , tf B <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ❑ o ❑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 ❑ o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan ' none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> t . cQJ APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* <br /> 545112(4/08) <br />