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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS ME G <br /> Zoning Status; CUP; tG <br /> OWNERADDRESS (Num er,iret1ity,State,Zi ) ��5'5r- Deed Restriction; CSM <br /> 1% W Variance(# ) <br /> HOME PHONE CELL PHON E-M I ADDRESS <br /> �'og- -37 3 �'y y 4,06)4_4� G G rti Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimension r( <br /> A AM AME CO CTOR NA E <br /> iii Site Plan including locatio <br /> AGENT ADDRESS CONTRACTOR D SS of well/septic <br /> // 96 cA- I /15l eft- <br /> (city,state,Zip) 3 S (city,state,Zip) �,.- ' �►��' Setbacks 915/101/(9/0 <br /> +I.!>/ S �/ 4 <br /> PHONE PHONE Site Plan approval from ,/ <br /> e g 8,_ 3 3 723 dB� 332 a "�� applicable township. /" <br /> E-MAILADDRESS <br /> E-MAIL ADDRESS <br /> Gl/ n . c-qy/ �G 6 v,/ el Ai! �x_ "pi/C 1,49. C()V Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property /f <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 1=1 PARCEL c112---122-_ j 0 d l7 g 5 frontage drawn to scale. 9 <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> fljt d , <br /> � i A' / 1/a:Se)-y '/a'/e: 'v WA Drivewa its <br /> (state, •i ,town) <br /> ADDRESS: x ,,,,,,e„ .5i�G <br /> // 2i C k ' 1 � / 'l�� Sanitary permits <br /> LOT SUBDIVISION BLOCK/LOT <br /> -- �_ (public, •> <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT Q�SCRIPTIOy:� ` `k f^ /!0 3 0 PC 2Z / * an trice ,A oc <br /> This project is a new building or structure. � � 5 <br /> • ❑ P 1 9 Wm-fitted tie-f,, <br /> ,{This project is an addition/alteration to an existing building or structure. <br /> . ti <br /> SANITARY SERVICE: PERMIT NUMBER: ra ure ':` <br /> SEWER nSEPTIC (ne ' " ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) P <br /> / ( 9 ) <br /> ��`e s• ,.3 ! <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ,,,4,-,'..} , €„i <br /> BASEMENT: 1ST FLOOR: A y <br /> .---- 2 V j TOTAL SQUARE FOOTAGE: + !+- <br /> I <br /> 2ND FLOOR( 3RD FLOOR: II ” <br /> view oonl Ivey <br /> ESTIMATED CONSTRUCTION COST: $ . B1� . .i t• a il <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ $ p , , ;.', <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes , 'No El 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? DYes 0 No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes 21No <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) -♦ ♦ —► <br /> 545-112(acos) <br />