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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> s r 'i ") ' Loa C)e rQ C'X . ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> C�w� Deed Restriction; CSM <br /> 3 <br /> �7 2& � Ai Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> uro gag 4/7)1 . 22c Svrl 'F its A) - a. tuo • <br /> Cow^'1 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRA TOR NAME <br /> tat N�A ❑ 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: +� CURRENTZONNIING:1 ACREAGE: <br /> ❑ <br /> NUMBER oat /oG/O`D2)"Q a4S fa�'1" , 2 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> fir- ("��lV E 1/4: , IA: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 34S9L Co,-.,4.•■ ei., VII 0 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION srArfitiViEw <br /> PROJECT DESCRIPTION: s <br /> Se.k_. GSD sa Ft 0 oning Dis fic <br /> ❑This project is a new building or structure. '°" tt y <br /> Permed Use's <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 R IA1dss <br /> fSEWER SEPTIC Anew/t# <br /> HEIGHT IN FEET: NUMB R OF STORIES: (Not including basement) Y <br /> II �, K e�d/Floodpl� <br /> AREA TO NEAREST SQUARE FOOT: Shorel ` ttanimen <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) `E o t <br /> BASEMENT: 1ST FLOOR: *; r , <br /> 1 TOTAL SQUARE FOOTAGE: 1 - a+ S ,$ rb; o-s4st 2ND FLOOR: 3RD FLOOR: c-�s..//�� <br /> ESTIMATED CONSTRUCTION COST: $ � ��� � <br /> (Please round to nearest dollar) "♦ ♦ ♦ ♦ ♦ ♦ z700,0„... a5. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ErNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes lo ❑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 R1"1' <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank i none) <br /> 6. Is a location survey required? (see reverse) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? El Yes ErNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/08) <br />