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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORM:17'0N CUS •MER TO PROVIDE <br /> OWNER N= 1 � ' /� <br /> j <br /> i h <br /> OWNS ADDR SS (Numbe `St` `ri reet,City,St}te,Zip) 'oning Status; CUP; <br /> b / „if U e5 f- # 1 Deed Restriction; CSM <br /> t Variance(# ) <br /> HOME PHONE b �p;5 C. U E <br /> O y—5V6( E-MAIL ADDRESS <br /> yv� Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ( 11-11A-/e__ —G„\.e • [r Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADD ESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Q Setbacks <br /> PHONE PHONE ' ❑Site Plan approval from <br /> ap 'cable townshi <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ loor pl s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CUR ENT ZONING: A ACREAGE: P P y <br /> ❑NUMBER Dql°'"031'L75.1 —f A —/ -pp pQ o 41,5-9 frontage drawn t ale. <br /> TOWNSHIP: SECTION: / 0000---0/706 <br /> I"`�C k %: N 141h: ❑ Driveway rmits <br /> ADDRESS: � � �� (state, unty,to - <br /> 5 �c �5 <br /> CSM: LOT SUBDIVISION BLOCK/LOT El S- Itary !' mltS <br /> ? S ©+ ` 3 aubli •rivate) <br /> (o i <br /> PROPOSED PROJECT INFORMATION - S AFF REVIEW <br /> PROJECT DESCRIPTION: <br /> I', X /Z k;A-k-tr✓ st,e.b r Z. ing District <br /> . Rfhis project is a new building or structure. E -ermitte. Ise? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBERS ❑ Rur. Address <br /> Y E <br /> FIEWER PTIC (ne - <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Flo plain/ <br /> Shorela (attachmen <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached g ages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: I—, <br /> Ero ionContro ermit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,dis rbance, <br /> filling/ac ss) <br /> 2ND FLOOR: 3RD FLOOR: J ESTIMATED CONSTRUCTION COST: ❑ an W ilabl On s. <br /> (Please round to nearest dollar) 'i ♦ ♦ 'i ♦ '♦ $ L(r�d0 - an availabl ptions. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 134,--['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes to <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? [Yes gao <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) ❑Ye Ero ❑Don't know <br /> 7. Is this to correct a violation? aes ❑No <br /> AI APPLICATION MUST BE SIGNED <br /> 545-112(4/08) © (Continue on Back) ■ —► <br /> • <br />