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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME l <br /> De,/ S` 0 6 El Zoning Status; CUP; <br /> OWNER ADDRESS(Number,Street,C4 State,Zip) <br /> Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ 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 CONT'•' .'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: CU ENTTZONING: ACREAGE: <br /> 1=1 NUMBER OG 1 0 �C� 0 X70 O K E— / , a.- frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> , ,/a. ❑ Driveway permits <br /> J n v\ /4. (� /a <br /> (state,county,town) <br /> ( y' own) <br /> - rliCDO Ropliae,r or <br /> Ca <br /> LOT LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION AFF REMEW <br /> PROJECT DESCRIPTION: <br /> )(1'S-1- i5x$ L) r 4L1 "art a ,. <br /> • ❑This project is a new building or structure. <br /> •p This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: • ural A.€dr <br /> SEWER nSEPTIC (nevi <br /> HEIGHT IN FEE : NUMBER OF STORIES: (Not including basement) <br /> I A2:1 V 1:,..,-..,/,', I r /1 <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) d Eros trot <br /> BASEMENT 1ST FLOOR: Iw�R <br /> TOTAL SQUARE FOOTAGE: 1 I S, � , <br /> -7 5+ �•OO _ �.� S <br /> 2ND FLOOR: 3RD FLOOR: <br /> 2)---7 5 <br /> ��1�t�w €� �'n survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ ♦ �� and�I�Options; <br /> (Please round to nearest dollar) $ S <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes p No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑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) Eyes ❑No ❑Don't know <br /> 7. Is this to correct a violation? DYes ❑No <br /> 70 <br /> 5545-112 1t2(aioa) S�'. • G3 APPLICATION MUST BE SIGNED <br /> I . (Continue on Back) ♦ —► <br /> fl <br />