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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME \ r, 1 <br /> $N D E 70 k-Z— S CA) 4 JQ-LIv\Q-S Le LJ W ti ❑ Zoning Status;CUP; <br /> OWNER DDRESS (Numb Street,City,State,Zip) r� <br /> 70 58 W44 V,6(9/0 D P Varriaia.-D Deed Restriction; CSM <br /> nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ,/bg 574 — 6C' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /f646 eQw 52(6J S'i' ( ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 35L 2 E pYPc o 4',21D <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> ate, P14 04rub 1 <br /> PHONE PHONE ❑ Site Plan approval from <br /> (414 33 —68 ?0 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 ❑ Elevation of property <br /> ❑ NUMBER 070 53 c y 8720 I 4 — I h 2 r frontage drawn to scale. <br /> T�1 4Dt-L-To 4 v SECTION: <br /> .1/4: ,%4,/4: ❑ Driveway permits <br /> (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: 1" REVIEW"' <br /> ID Ee- I`ixe-a,- ci x 8' byre.- . I », <br /> ❑This project is a new building or structure. <br /> CI.Permitted Use? lot:. . <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural ''Qoms jt , <br /> nSEWER VSEPTIC „ €3 <br /> HEIGHT IN FEET: l NUMBER OF STORIES: (Not including basement) <br /> D <br /> weteridffloodoopt <br /> Shoretand (attachment) ,' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR <br /> C)06 76 1 TOTAL SQUARE FOOTAGE: j sI� t�PDSfs+ r :` BCD, <br /> 2ND FLOOR: 3RD FLOOR: / ngt. <br /> ESTIMATED CONSTRUCTION COST: 0 Review Locate Survey <br /> QQ�� acid av <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ '♦ $ dc, ¥f <br /> ' u._ , <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 AIf o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Dyes MI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes E No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan i if none) <br /> 6. Is a location survey required? (see reverse) ['Yes O No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes OINo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 54`-112(4/08) <br />