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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> o� 0 4 F y ,- ilrtl l!n( G <br /> X 1117ecsfiing Status; CUP; <br /> OWNER ADDRESS (Number,Street,Ci ,State,Zip) <br /> "'i� !/' Deed Restriction; CSM <br /> �� ‘j ��- C _ v,) ��� 4 / /� 'f 7 Variance(# ) <br /> JHOME PHONE CELL PHONE E-MAIL ADDRESS <br /> /,-'7/Z -k. .// 1 /c ' 7 c4°r4 Ai - 0,5C-Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site I including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of W eptic <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> PHONE PHONE_ Site an oal from <br /> plicable township.appry <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Ele Ion of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> PARCEL C ontage drawn to scale. <br /> I NUMBER n$oq fly G6�- a- R-1 S�il�) g <br /> .1/ TOWNSH _.}— SECTION: <br /> / / ,` — -4.-. 7. 1/o: S 1/1/: ❑ Drivew.y .-rmits <br /> ADDRESS: G /J (state ••unty,town) <br /> CSM: LOT SUBDIVISION BLOCK�/LOT ❑ Sanita■ p-.- its <br /> (pub •, • 'vate) <br /> PROPOSED PROJECT INFORMATION F IIEW .'` <br /> PROJECT DESCRIPTION: /�/�J / / y/� .{/�/1 �/L l 1C/��A�� L�//'► <br /> \Q /oco. /Q� / �V ln� ! fit^ i zs 46 <br /> P <br /> ❑This project is a new l wilding or structure. ',, <br /> use y <br /> E -11 his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: J i;RUB ct �- <br /> SEWER (SEPTIC ' • <br /> �` '` 7, k <br /> HEIGHT I FEET: NUMBER OF ST 7ES: (Not including basement) <br /> ICs , w .,,pal ., <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) < <br /> BASEMENT 1ST FLO js � <br /> j TOTAL SQUARE FOOTAGE: + ka s• /®I t p <br /> 2ND FLOOR: 3RD FLOOR: ,, <br /> j� mss, -- <br /> ESTIMATED CONSTRUCTION COST: // and ,!fir O <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ $$ ,; <br /> r . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? II Yes ❑No ❑Don't kn• - <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ❑Don't kno <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? EYes ❑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 /> (Continue on Back) ■ -■ <br /> 545-112(4108) <br />