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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ■c, — ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> io\(�, L�• s-c <br /> 1/41.5 • ).•1•-5 . 53 9"\ Variance(# <br /> HOME PHONE CELL PHONE E-MAIL 3DRESS <br /> `,13-`'1(cs'1(0 5't - \-, • a-- p' c c ❑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 /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) I=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: <br /> ❑NUMBER O'5\ 1 S"S 1- , y p frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> '/1A: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> \E3\(p Cr�Lsv.(j - j&I <br /> CSM: LOT SVBDIVIION , BLOCK/LOT ❑Sanitary permits <br /> �, s� ���- (public, private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> ®This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> EWER 1YEPTIC <br /> '� <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 1 <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 /> 1 U (3 j TOTAL SQUARE FOOTAGE: j <br /> 2ND FLOOR: 3RD FLOOR: <br /> So <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) + '� '� "� $ C�.").% <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Uplo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes to ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? EYes o <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) Ekes Jlo ❑Don't know <br /> 7. Is this to correct a violation? Dyes ao <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ —► <br /> 545-112(4/08) <br />