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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 /> Cheyttr5 L 3VKctit — Oc,(AI T 6\ cn't „IA ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) Deed Restriction; CSM <br /> 19/ir S-e r k a-J r-17 y. ITV OY Pi's( t) , S 3S3 / Variance(# ) <br /> HOMEPHONE CELL PHONE E-MAIL <br /> !/o& `7Gil��5 t ❑ 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: CURRENJZONI : ACREAGE: <br /> ❑ PARCEL 1/. 7( y ,5 6-&-) frontage drawn to scale. <br /> NUMBER l <br /> TOWNSHIP: - nn SECTION: <br /> C' ff� p &r ci e° l ,, - '/4: '/41/4: ❑ Driveway permits <br /> ADDRESS: �� (state,county,town) <br /> v17�5 k r 6L4! b �i'I Y t <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> ❑ Sanitary permits <br /> 1 /...C.--- ( (public,private) <br /> PROPOSED PROJECT INFORMATION ,ST REVIEW <br /> PROJECT DESCRIPTION: <br /> a Z�Di k <br /> El This project is a new building or structure. <br /> � Permitted Lite'? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> s r <br /> SANITARY SERVICE: PERMIT NUMBER: 0 '" <br /> nsEWER (SEPTIC ! µ° q <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Ow l t �w a <br /> 5 s i. i ai, :, <br /> AREA TO NEAREST SQUARE FOOT: , ,Y-4,212';'" <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ��i rusicmoori ,,_ <br /> �" � <br /> BASEMENT: 1ST FLOOR: j TOTAL SQUARE FOOTAGE: j (slopes,distur ce, ! " <br /> tilGng/ar ss) <br /> 2ND FLOOR: 3RD FLOOR: <br /> Cl L. of" Survey <br /> ESTIMATED CONSTRUCTION COST: " 8 e o t. <br /> ♦ ♦ ♦ ♦ ♦ -, $(Please round to nearest dollar) � vi: <br /> . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ['Yes EINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Ei 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 RNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APIA UST BE SIGNED <br /> (Continue PL C on TION BacMk) -+ -0 <br /> 545-112(4/08) <br />