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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION <br /> OWNER NAME �j CUSTOMER TO PROVIDE <br /> -" ��� �'� Zoning Status;CUP; A4—/'--‹ <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> (Qij �'�C2„y b 1'7 Deed Restriction; CSM <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Variance(# ) <br /> t•1` Site Plan drawn to scale ' > a <br /> AGENT INFORMATION l CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> v ?7m 41 r UL's_ � �T M.Sit;,,:. - • udin location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of g <br /> �,� ����‘ � -II/septic //////��� � �,//,' <br /> (City,State,Zip) �z� ��ZC'!/d / (��/L/ )J/�( <br /> C � � (City,State,Zip) <br /> Setbacks / / ] ` <br /> PHONE _ PHONE Site Plan approval from.P <br /> (og'r'. 33 bog'- g 435 applicable township. /4 <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> E �- "� ' ` UG�4/S wiz— /Ni'Floor plans to scale r� <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) / �! <br /> ❑ PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ►. 'Elevation of property / <br /> PARCEL <br /> NUMBER O$// Zlo/ raw_f 4_ 3$ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> .,/j✓a i to +/4 +/4%4: e- gDrivewa ..: mits <br /> ADDRESS: `(state, ount town) <br /> CSM:ccJJ l/_' LOT SUBDIVISION BLOCK/LOT K� Sanitary p- �• s <br /> (public, .ij <br /> PROPOSED PROJECT INFORMATION ? �, ,< <br /> PROJECT DESCRIPTION:/ a 0 ( 2 2 ^ b Id <br /> ❑This project is a new building or structure. e -f <br /> ❑This project is an addition/alteration to an existing building or structure. �� 0%P c <br /> SANITARY SERVICE: <br /> PERMIT NUMBER: # ,: r , <br /> SEPTIC <br /> s r k / <br /> HEIGHT IN FVSEWER <br /> ' . ' is eaves NUMBER OF STORIES: Not including basement) ,A <br /> AREA TO NEAREST SQUARE FOOT: *IT41 °t <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: � $"1ST FLOOR: se 0 0 g®! 7 ,,, TOTAL SQUARE FOOTAGE: j s <br /> 2ND FLOOR: <br /> 3RD FLOOR: q <br /> ESTIMATED CONSTRUCTION COST: 1 <br /> (Please round to nearest dollar) ♦ "� ♦ "► ♦ ♦ $ G /, Q 00 O and <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(aios) (Continue on Back) —► -♦ .♦ <br />