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1'10 <br /> - ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> _ PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> I <br /> J I► Cc.,(4-er ❑ Zoning Statu ; CUP; <br /> OWNER ADDRESS umber,Stree i State,Zip) I / Deed a ction; CSM <br /> ii iISS Ct�f tc�t� C'ro l )X S���� Varian (# ) <br /> HOME PHONE CELL PHONE �J E-MAIL ADDRESS <br /> 7($3LJ7 4 413g ❑ Site Plan a scale <br /> AGENT INFORMATION �CONTRACTOR INFORMATION and includ dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well se <br /> ll u�se <br /> (City,State,Zip) (City,State,Zip) El Setbiks <br /> PHONE PHONE ❑ Site PI 14.•a • al from <br /> applicdbM • nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plaba'Gscale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevati n Of o <br /> PARENT PARCEL NUMBER: C RRENTZONING: ACREAGE: <br /> x Y <br /> ❑ NUMBER 0 IS/U7 I i-06�X440 a P. ` 1 , ( 5 g frontac r w to scale. <br /> TOWNSHIP: SECTION: <br /> TOWh.Qc (o e Grate_ 0Witec�,1/4: 1/414: Drive a mots <br /> P <br /> Th s: (statutown) <br /> C 1�1 vas LOT�� C SUBDIVISION lm dc�t� w-I— BLOCK/LOT�3��`� ❑ Sani ��'''•'f s <br /> OCCAP I (publ ,7 v:te) <br /> PROPOSED PROJECT INFORMATION ST F Revmw <br /> PROJECT DE(/SAC PTION: 1)2X-1Z <br /> µ <br /> . El This project is a new building or structure. " '.% .r <br /> 12 This project is an addition/alteration to an existing building or structure. ' 41:'''..* 4;;. <br /> 'a u <br /> SANITARY SERVICE: PERMIT NUMBER: f � � a <br /> nSEWER SEPTIC (new <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: aura -th <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Q E,�, <br /> BASEMENT: 1ST FLOOR: ,— <br /> 4, TOTAL SQUARE FOOTAGE: % ° + ',--,/,', <br /> 2ND FLOOR: 3RD FLOOR: /gag- ,41.ii4..„„,,_: , i,o,,,;„ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ $ / O 0 a Mkt <br /> (Please round to nearest dollar) $ a � ? <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes V No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Ee 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 IZNo <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 F4No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -► -+ <br /> 545-112(4/08) <br />