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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web.App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NAME J <br /> 6 o tel..h r ❑ Zoning Status; CUP; <br /> OWNER ADD ESS (Nu ber,Street, e, p) T _ �,� C� <br /> 3 736 5 4 1 4 `�� 5 / (rJ[ 5-35-3 Deed Restriction; CSM <br /> i l O 7 , �-- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS '- nn rr <br /> 6'e P3795 i3 6�576 '2F3 VoKi/`d b6/K��. 4o L s c,J❑ Site Plan drawn to scale <br /> AGENT INFORMATION (CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTO AME <br /> .50171 — 643,4_, ❑ 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-MAILADDRESS <br /> • ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> pn /� frontage drawn to scale. <br /> ❑ NUMBER o i y�0 vie -03y-X5-1._ 7 R.3A , q <br /> TO HIP: SECTION: <br /> j r,,Q 1/4: ,/1/: ❑ Driveway permits <br /> c ° ° ° (state,county,town) <br /> ADD ES$:3 / IL! h g <br /> �� lD BPS (�( �3 5 3 Z <br /> El Sanitary permits <br /> CSM: LOT .2 SUBDIVISION BLOCK/LOT (public, private) <br /> 7/66 <br /> PROPOSED PROJECT INFORMATION 7 -TAFF RE j j. <br /> PROJECT DEIS�O� ` (1 s FA <br /> i El '®twig s, ?ems; : <br /> This project is a new building or structure. " -°` <br /> 21 This project is an addition/alteration to an existing building or structure. � �' <br /> SANITARY SERVICE: PERMIT NUMBER: �,,.eX twea £ <br /> SEWER SEPTIC o g -- " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) *�''"' � "- <br /> /off' 3., / ® tapeM:oe awnl <br /> `;s bore an. a c eeriW <br /> AREA TO NEAREST SQUARE FOOT: r j,- <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) �� <br /> ( 9 9 9 9 P ) 7-:.. .;',t,;-7, -„- <br /> as <br /> BASEMENT: 1ST FLOG T. e p @ <br /> fa1 � f <br /> S 4, TOTAL SQUARE FOOTAGE: 4, o e e e � <br /> 2ND FLOOR: 3RD FLOOR: ?1 , y r m <br /> r - e- <br /> ESTIMATED CONSTRUCTION COST: -+ ♦ --0. ♦ ♦ -•► $ 3 -00 O� o o epa.e <br /> (Please round to nearest dollar) , .,„:;:r:.? , _ .:- . ---, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Dyes El No El Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ElYes ❑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) ❑Yes No ❑Don't know <br /> 7. Is this to correct a violation? Dyes , No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -4 -+ <br /> 545-112(4/08) <br />