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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME -0` ` <br /> ��-�C !�"1` Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) .� Deed Restriction; CSM <br /> ∎L\\ 1 )T5\ \\ c L �-- r\eC_ L,0\ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> at p- ' Al Site Plan drawn to scale 7 <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions Q <br /> AGENT NAME CONTRACTOR NAME �W <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic �/ <br /> (City,State,Zip) (City,State,Zip) Setbacks 63/306//0 <br /> PHONE PHONE 'Site Plan approval from AV <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> WS Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT P EL NUMB CURRENT ZONING: ACREAG p P y <br /> ❑ PARCEL %4/Z '16'1 gs`4—0 A- 1 Lam', 6z_ frontage drawn to scat <br /> NUMBER ! G,7C <br /> TOWNSHIP: f rr SEC /�t ,y/ �, / <br /> C ✓ 1, S r 1 C 17 1/4: Y r . 41/a: /`/ )' Driveway permit, <br /> ADDRESS: (state, county, <br /> 5A � � �,{ <br /> CSM: LOT SUBDIVISION BLOCK/LOT �l Sanitary •- its <br /> ..--------- (public, <br /> PROPOSED PROJECT INFORMATION K AF1 IRI <br /> PROJECT DESCRIPTION: �� �.; <br /> 2' (,JOo� ': zonesD� , i <br /> . OZIThis project i or structure. %U <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Murat ` a^ <br /> nSEWER SEPTIC <br /> HEIGHT IN FEET: / 2_ NUMBER OF STORIES: (Not including basement) { !� <br /> AREA TO NEAREST SQUARE FOOT: "',rta€.�F� 4 �� <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> permit to.-- <br /> BASEMENT: 1ST FLOOR: (/ £ # <br /> S� /y 1 TOTAL SQUARE FOOTAGE: j •+ , ' of ' # , ' / <br /> �I�o �4... 'r <br /> 2ND FLOOR: 3RD FLOOR: Lc V„n L 1 1 <br /> f <br /> ESTIMATED CONSTRUCTION COST: ', Q -, ° �� 0 <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ �00 0, Oo <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? EYes ❑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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> J �� � �© <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4 08) /�Q 1 (k) {6 Continue on Back`zlU ' ' <br />