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21 , 103 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW ER NAME <br /> t-r'eGf MCTI/-05) ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,Stt te,Zip) _ Deed Restriction; CSM <br /> 6'170? Br evn"a R Ka zo Q'n i e k/1 5 3500 Variance(# ) <br /> HOME PHONE / CELL PHONE E- AILADTRESS, ) <br /> 01;"-P/3—',/6/4. <br /> ►i;'6`l3"3/�b re/�/1 /�4 �L�11s //C0fr❑ Site Plan drawn to scale <br /> AGENT INFORMATION 1 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) <br /> (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/) ID Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> El NUMBER 0 (07-353 4,SW .) Al EC frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> D , <br /> .1/4.1/4: ❑ Driveway permits <br /> �l0 <br /> L. • �' (state,county,town) <br /> ADDRESS: / / <br /> /7O7 BrP4 f1 i /I s /J1' ❑ Sanitary permits <br /> CsM: / LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION � ST A,F VI" W <br /> -".- ,? E 12 <br /> - <br /> PROJECT DESCRIPTION: C,ftle, e , <br /> . ❑This project i a new building or structure. 1 ° <br /> ❑This project is an addition/alteration to an existing building or structure. . , f� : �'�,`y <br /> SANITARY SERVICE: PERMIT NUMBER: l ,� <br /> F1SEWER �IC o ,,. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) -e �-=a <br /> 77 , e ° °ooeta <br /> p'D� .N. ore ane attac'hrrienfj <br /> AREA TO NEAREST SQUARE FOOT: "- =„ �"" . "` °` '' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) -.- ,-6.,,,,,o...,., . <br /> BASEMENT: 1ST FLOOR: ' ` i'' <br /> 1 95'0 4, TOTAL SQUARE FOOTAGE: ° ° ° � <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: $�� 0� <br /> ?rW 0'4:12°°i.:9 �`�}'t: ,, <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �P °, " b <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? ❑Yes ❑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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -9 <br /> 545-112(4/08) <br />