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ZONIN a PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME / <br /> A AA/0 ' d` T N <br /> 5" ''f/ if„TA HA R E IS ❑ Zoning Status; CUP; <br /> OWNER ADDR SS (Number,Street,City,State,Zip) <br /> I y 2/ Go � / l Rb P Deed Restriction; CSM <br /> /f Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 100 7'7 11815 60g 3'i? 1 q 25 A, W bN/qP--5 e 7 f. LI 'T ® Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 14 Site Plan including location <br /> AGENT ADDRE•S CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Co Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRE•S E-MAIL ADDRESS <br /> [X Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONI G: ACREAGE: El Elevation of property <br /> ❑ NUMBER 0 z 0/0707.342 e i 2,,0'0 Ai (6...>( 2 A 341 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> C a b SS P L R RNs /4: 1/4/4. ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3 11 21 Lo '/kY 12.o P <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION € s- <br /> PROJECT DES 4 RIPTION: t" > x <br /> 1: !�i of; 2-'A R G,�kA a S x�0 2 _! �� <br /> • I'This pr. ect is a new building or structure. V Kr ` i x <br /> x nl <br /> ❑This pr. ect is an addition/alteration to an existing building or structure. p � - <br /> SANITARY SER ICE: PERMIT NUMBER: `:- y r" <br /> ,I SEWER ®SEPTIC ', , <br /> HEIGHT IN FEE : NUMBER OF STORIES: (Not including basement) p ` l . <br /> 10 PP Ao 1 MdTc 4 !, <br /> AREA TO NEAREST SQUARE FOOT: ��ykf s 7 e pg �14 <br /> (Outside dim:nsions including unfinished area, attached garages and above grade decks or porches)BASEMENT: 1ST FLOORr ` f <br /> 2,0 x 2-6 i TOTAL SQUARE FOOTAGE: 1 3 3 g <br /> 2ND FLOOR: 3RD FLOOR: Soo �y 1-7- ,� <br /> q <br /> ESTIMATED CONSTRUCTION COST: --► ♦ -► $ 1 3 sY ,$ Y <br /> (Please roun. to nearest dollar) i b , . ...;,. _ f._. <br /> 1. The prop:rty is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes N No ❑Don't know <br /> 2. Is there a etland or floodplain on or near the property? ❑Yes No ❑Don't know <br /> 3. Have you alked with the township about your project and are they in agreement'? [xi Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? EYes NNo <br /> 5. Is this pro -ct associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> ❑ <br /> 6. Is a location survey required? (see reverse) Yes No ❑Don't know <br /> 7. Is this to •.rrect a violation? ❑Yes fNo <br /> g - v� , APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />