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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVID <br /> OWNER NA <br /> OWNERADDKESS�m /� L& Y Zoning Status;CUP; ' <br /> qq ( r, treet,City,State,Zip), / r Deed Restriction; CSM /`� ' <br /> ll> 4-t`— Del C�I�C���-� t � ``' �� � Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS _ / <br /> 608 -1�'c( u "1�. COQ ►4 Site Plan drawn to scale <br /> AGENT INFORMATION CCNTRACTOR INFORMATION �� <br /> and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> o' Site P -• ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS •' well/septic <br /> !0 <br /> (City,State,Zip) (City,State,Zip) T 1 Setbacks 340A V/Q�� <br /> PHONE PHONE 'Site Plan approval from /V� <br /> applicable township. //I} <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> a Floor plans to scale / It <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT P R�`;L NUMBER: A CURREN�jZONING: ACREAGE: IZ Elevation of property <br /> ❑ NUMBER �J / Z y���l/3 K r f/ 'Z , y frontage drawn to scale. <br /> TOWNSHIP: A I N D v-) SECTIQ /: //: � - <br /> Driveway permits_ <br /> ADDRESS: ""'•. ;�■ <br /> cSM:52 �ZQ LOT / SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> L (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> P-. CT ESCRIPTION: / / �a �� ' <br /> ❑This project is a new building or structure. ` fCi ►, ermitt tlse' <br /> ❑This project is an addition/alteration to existng bui S lding or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ■SEWER C SEPTIC . =. <br /> HEIGHT IN FEET: ■ NUMBER OF STORIES: Not including basement) � .; <br /> AREA TO NEAREST SQUARE FOOT: Zattachment) /L <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ► !e,,!7- <br /> j/ I/ <br /> �. p-ITT <br /> BASEMENT: 1ST FLOOR: /�-- / O <br /> J1 �/ <br /> 4, TOTAL SQUARE FOOTAGE: 4, :1 r":,,L.,,, <br /> 2ND FLOOR: 3RD FLOOR: S// l I ; ' <br /> 7 `+ <br /> k 9 ii. <br /> ESTIMATED 6,'1,$a W ri <br /> ESTIMATED CONSTRUCTION COST: /,� . <br /> (Please round to nearest dollar) ♦ ♦ '♦ ♦ ♦ _' D DDD <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(4/08) <br /> (Continue on Back) ■ -► <br />