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ZONIN t ERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE ME M <br /> Ma s---;AA 4 ' '") ❑ Zoning Status; CUP; <br /> OWNERADDR:. (Number,Street,Cit ,State,Zip Deed Restriction; CSM <br /> l9 S Pfci(o s� Usti„ � , w ( s 3 5 3 Variance(# ) <br /> HOME PHONE CEL HONE E-MAILADDRESS <br /> Oa. S.7 S2 c�7 m. 5 F-5.it � it'ca~f , co----) ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE T AME CONTRACTOR NAME <br /> r (s ❑ Site Plan including location <br /> AGNT ADDRE Co NT R AD DRESS of well/septic <br /> c y (4 <br /> ( „,p), (City,Stae,Zip) ❑ Setbacks <br /> (/ A W ( f3S — <br /> NE <br /> / PHONE ❑ Site Plan approval from <br /> &60— —co (o�j pplicable township. <br /> E- AILADDRE` /� L E-MAIL ADDRESS <br /> u o �. 5 147JS■✓12-4 ❑ Floor plans to scale <br /> PROPERTY LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL 25482 S oo frontage drawn to scale. <br /> NUMBER O� 0-7 <br /> TOWNSHIP: SECTION: <br /> 5P r, • d I a� 1/4: N e 1/41/4: S E ❑ Driveway permits <br /> ADDRESS: V ' �� (state,county,town) <br /> CSM: <br /> I/ s a S” r4 LaT'occ 0_e.e ,,_ ( c3 e? 3LOT ❑ Sanitary permits <br /> 1 0 4-3 . ( (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF RVIEW,4 <br /> PROJECT D�ES•-I TION: ' ' <br /> ���11Y//�Y• lr lll(�I�v�.t�W SW•, ,L F '. /+) I <br /> f ' <br /> E This pro -it is a new building or structure. <br /> U;'. t <br /> S , t't3U 7 <br /> , <br /> ❑This pro -it is an addition/alteration to an existing building or structure. <br /> �z <br /> SANITARY SER IC:: PERMIT NUMBER: U tiri A re s <br /> S WER nSEPTIC <br /> t c°,iar s 6,--,t,' <br /> HEIGHT IN FEE NUMBER OF STORIES: (Not including basement) <br /> I, . k . <br /> in mho <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dim:n-ions including unfinished area,attached garages and above grade decks or porches) % ., <br /> BASEMENT: 1ST FLOOR: ��' ; ': <br /> +, TOTAL SQUARE FOOTAGE: ,_f(1StUtMB"1{ , <br /> 2ND FLOOR: 3RD FLOOR: t <br /> 8�'' <br /> ESTIMATED INSTRUCTION COST: 2 ��- / #IE;Up$ t <br /> (Please roun, to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ 0/ +nd a ,,,, ,y-- <br /> 1. The prop-rt is within 300 feet of a stream or 1000 feet from a pond or la ❑Yes r. o ❑Don't know <br /> 2. Is there a :tland or floodplain on or near the property? Eyes 7 No ❑Don't know <br /> 3. Have you al ed with the township about your project and are they in agreement? ®.Yes ❑No <br /> 4. Has there b:en a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this pro.-• associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a Iocati•n survey required? (see reverse) Eyes !No El Don't know <br /> 7. Is this to ••recta violation? ❑Yes 1No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ -* <br /> 545-112(4/08) <br />