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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME `��� <br /> �+1 RC )%,S ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) _ <br /> S 3S � Deed Restriction; CSM <br /> 3766 1�\.Wrso►N ki) S7'a., . a,-, 1�'+ 9 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 60$ 2,O1-62.b3 S A ++c J bell- MO °'eta•Con ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAM <br /> ,kr ,o‘lStft, ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 5 ■t1L A5 PFo11 t <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/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ NUMBER b 6)b -279-9 3 C,D -0 AZ CI ) 1.-15 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> (� <br /> +"'►„h 2-4 14: <br /> .1/4,4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3764, Vb,s(, RD <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> \ 95-7 ' (public,private) <br /> PROPOSED PROJECT INFORMATION „:, <br /> PROJECT DESCRIPTION: ' REVIEW <br /> . [X]This project is a new building or structure. <br /> EI Permitted Use? _ - <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> -SANITARY 0 2ural�ress <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> MSEWER SEPTIC r ,i ,ti y .z <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 14 1 Eiea • . ., <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) Li 4 EroS1 It f ntroll permit <br /> BASEMENT: 1ST FLOOR: / 1 <br /> 30 ( Q 4, TOTAL SQUARE FOOTAGE: 4, S�S,4 4 re.,,,4 , E <br /> 2ND FLOOR: 3RD FLOOR: <br /> /p 0O. y <br /> ESTIMATED CONSTRUCTION COST: ) ` ' Pa viU11f <br /> ♦ ♦ ♦ ♦ ♦ ♦ $ e ”° options <br /> (Please round to nearest dollar) 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? t]Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ['Yes g No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? EYes 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 1No E]Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -, <br /> 545-112(4/08) <br />