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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 /> �C f/./�� !� A( /f 6 �' ❑ Zoning Status; CUP; <br /> OWN A �ss (Umber, �t,city,State,Zip) �, Deed Restriction; CSM <br /> / er r/j/A 2 i wS«. ��'��� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS IN <br /> (,2 3 L)b� the S 2 Q (-"` Y"" +e""�`- Site Plan drawn to scale <br /> AGENT INFORMATION I 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: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER O(,^/() /2 ..-3‘4. 4)--. `� � e�G s frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> �,,,� 0i.--: . 0 A 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> / ZG /TA-Lt%< 1 k- — e �� 1=1 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION $ �tF IEW <br /> PROJECT DESCRIPTION: i : y �; <br /> d Zoning Dis <br /> ❑This project is a new building or s ructure. 0 Permitted U <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Q Rural Address <br /> nsEWER SEPTIC `'(new/existing) -' ; <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2 2_ 1 AREA TO NEAREST SQUARE FOOT: � � <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ,e'''' <br /> BASEMENT: 1ST FLOOR: o permit <br /> �] 4, TOTAL SQUARE FOOTAGE: 4, ( — w ce, <br /> l Alin%€ <br /> 2ND FLOOR: 3RD FLOOR: <br /> -7� a <br /> ESTIMATED CONSTRUCTION COST: <br /> ( ) �5 �D Bt: 6A` <br /> Please round to nearest dollar ♦ ♦ ♦ ♦ ♦ ♦ ''S Imo. 4—P4 <., ,...,, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes E No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 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 5iNo <br /> 't (f ` APPLICATION MUST BE SIGNED <br /> (f on Back) -+ <br /> 545-112(4/08) <br />