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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #iss3 <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME` '` <br /> jinn 1 (O . S t[/"Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 10 3 S .l.Ah ill ck Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> acoagoa 51(Q(p ennRowc rs 3 301 CEou6.c-DO1❑ 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 1 ❑ 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 /> ❑ NUPARCEL MBER 0910-19'1_001S_B 'R-1 D , 5-78 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 1/O jNDSO}2 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> -7(DU3 SoUWv 41-I« RoL <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: �\ ,j <br /> . p TCK_ 0 <br /> � * trict� <br /> ©This project is a new building or structure. sU P��use? <br /> ❑This project is an addition/alteration to an existing building or structure. 'y0‘ <br /> SANITARY SERVICE: PERMIT NUMBER: �' #,fresh <br /> SEWER SEPTIC V ° <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> a /)1iO�w�1 � s'1%',,,,:,':-.;7.,,, 4tvirt <br /> t 1 `A S Orelan (attachment) .' <br /> AREA TO NEAREST SQUARE FOOT: ae s: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> i� ?S t 1t OIlfi.71.• It <br /> BASEMENT: 1ST FLOOR: t � � zia$l 1,•1; ry, <br /> 1 TOTAL SQUARE FOOTAGE: $, s 4 <br /> 2ND FLOOR: 3RD FLOOR: <br /> Q Review o on Serve <br /> ESTIMATED CONSTRUCTION COST: p o � ,, ,:'2;i:4',''',‘ <br /> (Please round to nearest dollar) ti/000 � n' xe"= <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 LJ 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 E No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> 1 s_ SD APPLICATION MUST BE SIGNED <br /> br (Continue on Back) <br /> 545112(4/08) <br />