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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM} �p <br /> q `eW b <br /> '` ` e'rthn'e, ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> y�-oz M- 0-w bM,MorriSc(WViII-etw1 S3s---3•i Variance(# ) <br /> HOME PHONE CELL P ONE E-MAIL ADDRESS <br /> '10•$141• C2 g e to n c& hofimA+ i i cam ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> [ t 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/) 1=1 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑ PARCEL obis/oq 10-via 44 sao,l R.-3 1(D frontage drawn to scale. <br /> NUMBER o <br /> TOWNSHIP: SECTION: <br /> W 1 nd so b b. 'r4: SW '/4'/4: N W riveway permits <br /> ADDRESS: (State,county,town) <br /> 4402- C 4wki IbM ❑ S- .ry permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public;,private) <br /> t0 <br /> Li <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C c C " District" <br /> This pnject is a new building or structure. . Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SER E: PERMIT NUMBER: I '� <br /> SEW �-y4• � . <br /> HE"/IG�HT IN ET: ` NUMBER OF STORIES: (Not including basement) F <br /> TO NEAREST SQUARE FOOT: <br /> : a attachment) <br /> ) <br /> (Outside dimensions inc u•mg unfinished area, attached garages and above grade decks or porches) w <br /> BASEMENT: 1ST FLOOR: r ; <br /> (c._es 4, TOTAL SQUARE FOOTAGE: 4, • • . ' k= r <br /> 2ND FLOOR: 3RD FLOOR: <br /> US/ ,a <br /> 1 1,11 R t0OC1 U <br /> ESTIMATED CONSTRUCTION COST: <br /> ' O ' �(Please round to nearest dollar) '♦ ♦ ♦ ♦ "∎ ♦ $ ) Z Loc.), i , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes gI No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ['Yes X❑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) EYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? EYes Ei No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) <br /> 545-112(4/08) <br />