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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNEg�iAME <br /> \Jr^+- 6i--t)() ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Stfeet,City,State,Zip) Deed Restriction; CSM <br /> i_13 3c) co�L- 1-i l i Pr ' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ecl --a-35 °8&E l 5. W h r ' .3e 0-0 � °"-, ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <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 /> El Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> I=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURB T ZO G: ACREAGE: <br /> ❑ PARCEL 0 y,l)_ 1 0-9S frontage drawn to scale. <br /> NUMBER �O3- 1(125-O_ <br /> TOWNSHIP: SECTION: <br /> '/a: '/4'/4: ❑ Driveway permits <br /> 7;,,,,SS: 04 �,' odic., (state,county,town) <br /> ADDRESS: <br /> r ? g I C ;I L )--j' 11 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 3 5 ( <br /> G �� (public,private) <br /> d(Ir <br /> PROPOSED PROJECT INFORMATION ST" " F .4 EW <br /> PROJECT DESCRIPTION: <br /> }'fie c-I= ( )N( 1 ).: ) 1:1 ' II 0 District <br /> r <br /> . ❑This project is a new building or structure. © Permitted U <br /> :-,-;-iii„ * <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVI E: PERMIT NUMBER: ✓0° 11.,. ; fMA* <br /> SEWER nSEPTIC � { <br /> HEIGHT IN F T: NUMBER OF STORIES: (Not including basement) �� <br /> crelend (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> 13 Erosion o . ‘,.,0e,.. : <br /> BASEMENT: 1ST FLOOR: <br /> //11 + TOTAL SQUARE FOOTAGE: + ' �� $'° �` <br /> 2ND FLOOR: 3RD FLOOR: <br /> Review t ?: Survey <br /> ESTIMATED CONSTRUCTION COST: �ava 1 e :i 4 a ', 1 <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ %SDC) lti <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes krw! No ❑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'? Yes •No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Yes 0 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 EiNo El 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 />