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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N/1ME <br /> ow E �" ej /9 '�//7/ Zoning Status; CUP; <br /> ADDRESS (NyMber,Street,City,State Zip) ❑ <br /> �7 4 7/;74 J- /47,g- Deed Restriction; CSM <br /> SELL Variance(# ) <br /> .OME PHONE CELL PHONE E-MAIL ADDRESS <br /> .‘e$ ZytT_27Z8 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGE T NAME CONTRACTOR NAME <br /> Ci /ile.r 3/./ 4.-/ ❑ Site Plan including location <br /> AGENT ADDR SS A ;J )t, CONTRACTOR ADDRESS of well/septic <br /> /3b3 _(Are/fe <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> no, 1 h ' 5:7 7/‘ <br /> P ONE PHONE ❑ Site Plan approval from <br /> fig 2Z//3f applicable township. <br /> AlL RESS E-MAIL ADDRESS <br /> f.e/"/Aeea si 7.2,0d7/4e.71 ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ 11/4J -"'7/0-OS/-2793-Z ' 3 , 2 yS7 frontage drawn to scale. <br /> TOWNSHIP: //'� SECTION: <br /> �� !%/!y Ca/'UVt? 1/: '/a'/a: ❑ Driveway permits <br /> ADDRESS: J (state,county,town) <br /> — y/2 '1 i 4/ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> I�PROU FF�te, <br /> JECT DESCRIPTION: , a, <br /> /1,6 C. /0 / O Zona i Itict <br /> • ❑This project is a new building or structure. <br /> .ems l This project is an addition/alteration to an existing building or structure. k, <br /> �'SANITARY SERVICE: PERMIT NUMBER: a� <br /> V1SEWER nSEPTIC (newle 4 • /Y°' <br /> HEIGHT IN FEET:41 NUMBER OF STORIES: (Not including basement) a <br /> AREA TO NEAREST SQUARE FOOT: �� <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) de_",,,,'__& <br /> BASEMENT: 1ST FLOOR: <br /> /72-.6--/72-- 4, TOTAL SQUARE FOOTAGE: 4, r d 7 a •;0';--,,,,,,/' <br /> 2ND FLOOR: 3RD FLOOR: $r . 3, ) /i <br /> ESTIMATED CONSTRUCTION COST: <br /> _ . .. ,u� <br /> (Please round to nearest dollar) <br /> -► � ♦ -► ♦ -♦ $ ./�0Dt�6 , I y�� �� <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 ❑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 ❑No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aioa) (Continue on Back) <br />