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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME //e <br /> 'Inc Ti ie ❑ Zoning Status; CUP; <br /> OWN A ESS (Number,street,Cit ,State,7ip) l 4 C r Deed Restriction; CSM <br /> � �� (v/ L Variance(# ) <br /> HQME�ON 5"O JELL PHONE E-MAIL ADDRESS <br /> 6 02- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACT R NAME ��1 <br /> /© A1-6-6/( DO a Ot ❑ Site Plan including location <br /> AGENT ADDRESS CONTRA TOR ADDR SS of well/septic <br /> I(S-0 X4/41 S r E -.7—" <br /> (City,State,Zip) (City,State,Zip) p R /� , ❑ Setbacks <br /> SUN <br /> PHONE PHONE 3 3 510 ❑ Site Plan approval from <br /> 605' eas q 595 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: u CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0(1D Z3 /$ZSn0 r - 3 ©.. /6 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> kV YN � 1/4 <br /> 3 . 1/41/4: E] Driveway permits <br /> ADDRESS: I (state,county,town) <br /> 0 Sc 0 0 t L ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> I Z. 333 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW `` <br /> PROJECT DESCRIPTION: a" <br /> • <br /> 11�` Lt <br /> . in This project is a new building or structure. t - = %i <br /> ❑This project is an addition/alteration to an existing building or structure. ' <br /> SANITARY SERVICE: PERMIT NUMBER: s o <br /> EWER (SEPTIC e 4 1 <br /> HEIGHT IN F ET: NUMBER OF STORIES: (Not including basement) <br /> ;yam <br /> iftir• 3. 6 1v", etlano. o00i A <br /> c =mho. _ . .r0.141-t)� <br /> AREA TO NEAREST SQUARE FOOT: �. � <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) y ;4 -' <br /> o s e e o <br /> BASEMENT: 1ST FLOOR: <br /> 0 1 TOTAL SQUARE FOOTAGE: 4, e 1 •• • ! an w <br /> O <br /> e a <br /> 2ND FLOOR: 3RD FLOOR: 7 O ,3,..-14,7,:,� i <br /> O :tom ft s a✓ s - '' <br /> ESTIMATED CONSTRUCTION COST: -€ e�sa t e` :? <br /> (Please round to nearest dollar) ♦ -► ♦ -► -► -► $ I 100 p <br /> / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? El Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes E 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) p Yes Fl No ❑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 />