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A240 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> a it i c h7 �J-T <br /> 13✓5-5 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> '7 /Iwo C/ S-7eLi.h -nn w l 6-36-635 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ,,, _ ;)7.-t, 2 3 60?- 2,06-2?83 ❑ 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, - -, ip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS V_' E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dlane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: 0 CURRENT ZONING: ACREAGE: <br /> ❑ <br /> NUMBER <br /> PARCEL <br /> //- - 33_53�O� G 1_ 7�Q frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> .PC/100 1\ 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: q (state,county,town) <br /> y i LeGi re ❑ Sal + <br /> a': t <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pL� a <br /> PROPOSED PROJECT INFORMATION STAFF REVIIII <br /> PROJECT DESCRIPTION: /,,fr- <br /> 11 This project is a new building or structure. 0 P- {� � y <br /> El This project is an addition/alteration to an existing building or structure. ' <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural -° -- <br /> nSEWER SEPTIC (new/existing) <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: # a <br /> (Outside dimension including unfinished area, attached garages and above grade decks or porches) '4 <br /> BASEMENT: 1ST FLOOR: Q Ero0, tf4i `, <br /> 1 TOTAL SQUARE FOOTAGE: 4, (°°,# ,,.,,i t ance, <br /> I �-,. s <br /> 2ND FLOOR: 3RD FLOOR: n <br /> y Review fiO gttr4 <br /> ESTIMATED CONSTRUCTION COST: ,. t '+ a <br /> (Please round to nearest dollar) '♦ ♦ ♦ ♦ ♦ ♦ $ 5000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? E Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ®Yes El No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? In 0 N <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes in No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#/2,70y ) (leave blank if none) 7�i`1g1 <br /> 6. Is a location survey required? (see reverse) IN Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? E Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -♦ <br /> 545-112(4/08) <br />