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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME y <br /> 3 -&V-q 4. K .e.31 S?o ' ' --0-let , ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 1 0%k (_4 i"e1� �X , (v\ .. or'Lab Deed Restriction;CSM <br /> HOME PHONE CELL PHONE Variance(# ) <br /> E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME (� CONTRACTOR NAME <br /> N..'' \ . ', '\ (o,e)n:., c„,,k.0, \ osti,,A C ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> w 32ral% va b►,woZ <br /> (City,State,Zip) (City,State,Zip) <br /> AV.1lst w� 736�l ❑ Setbacks <br /> � <br /> PHONE PHONE El Site Plan approval from <br /> VOcb 6-ii ct'3 (0 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> �tet 4'a. ,-o ©\ " vrui l•4+t ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: ' r CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER o4cg (D 507 $%%`64(5 o 4� P- Z. frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> dRv'% V o .1/4: x/4+/4. ❑ Driveway permits <br /> ADDRESS: 1if � (state,county,town) <br /> 10 1 io e <br /> CSM: LOT SUBDIVISION BLOCK/LOT El Sanitary permits <br /> 31°LA ‘ (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF IREV <br /> PROJECT DESCRIPTION: <br /> �� �fl � <br /> �1 <br /> This project is a new building or structure. --' <br /> 1d g t`Permitted Ise? ?; <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 u;)' �r r <br /> nSEWER SEPTIC (n,140 p <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) h ,, , <br /> AREA TO NEAREST SQUARE FOOT: r <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) - ' . r i p <br /> BASEMENT: 1ST FLOOR: • e + <br /> 23 Z9 153 TOTAL SQUARE FOOTAGE. F 4,'..+1,1,-,e, slot r:47e. <br /> 2ND FLOOR: I ) �t • <br /> 3RD FLOOR: <br /> -tta t-77-,/e U �LU <br /> ESTIMATED CONSTRUCTION COST: '-�4; '' ray- <br /> (Please round to nearest dollar) —∎ ♦ ♦ ♦ ♦ ♦ $ 4 C:7V�d V .0 ava • •• • .. <br /> V N' ., <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EgNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2 No El 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? El Yes ^; INo <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 ©No <br /> Sl'-. /.- ! Ej APPLICATION MUST BE SIGNED <br /> 545-112 laioa> (Continue on Back) —► <br />