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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME I <br /> OWNER ADDRESS (Number,Street,City, Zip) <br /> ❑ Zoning Status; CUP; <br /> S-01 -,/1i'S f'r A)S d ) ,42 . Deed Restriction; CSM <br /> HOME PHONE CELL PHONE Variance(# ) <br /> E-MAIL ADDRESS <br /> .1 /7 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME c <br /> AGENT ADDRESS f f�� L'0�,/' ` ❑ Site Plan including location <br /> CONTRA TOR ADDRESS of well/septic <br /> (City,State,Zip) / / 3L S. S y- <br /> °(.1. ,42 A �r� <br /> (city,St p) ❑ Setbacks <br /> PHONE PH ❑ Site Plan approval from <br /> .07 r ) !6 y applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> // 0, r^r # ,, a 4 •44 ( old ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CUR NTZ NING: ACREAGE: ❑ Elevation of property <br /> El NUMBER 0 7 00 5-I��L15`9 T Z T /off frontage drawn to scale. <br /> TOWNS P: SECT ON: <br /> 00mA 6 r J e 'h: '//: ❑ Driveway permits <br /> ADD s: (state, county,town) <br /> CSM:a tslb LOT sew ivy ❑ Sanitary permits <br /> SUBDIVIS BLOCK/LOT <br /> `j (a V���! Ai (public,private) <br /> PROPOSED PROJECT INFORMATION 4 <br /> �PROJECTDESIPTI�N: ( *,,,D� /l► ri / / v - n <br /> This project is a new building or structure. .; <br /> This project is an addition/alteration to an existing building or structure. <br /> �ASANITARY SERVICE: PERMIT NUMBER: a; r <br /> T. EWER nSEPTIC (new! ga e1 i� <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) , <br /> / 3 ' a s s s,o- <br /> ee AREA TO NEAREST SQUARE FOOT: 2� Incit� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) '� ,, �' <br /> BASEMENT: 1ST FLOOR: • ' <br /> 5IcSi + TOTAL SQUARE FOOTAGE: 4, <br /> 2ND FLOOR: <br /> 3RD FLOOR: �6Z)50- n� �� t�� �� <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ��/v <br /> 4C( 47 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Lallo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? JYes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes VINo <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 /> ud <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) Y/ (Continue on Back) <br />