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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME{ �/ <br /> _i0el C�/ '�L 7 ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ,/� Deed Restriction; CSM <br /> �I l.4�Gi 7 t/ �� . f t a � *l, ( 6'"�I E Variance(# ) <br /> HOME PHONE cr, CELL PHONE E-MAILADDRESS <br /> O Z3� I ' (Ea0�'- I I SI 01) a' h 64' ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5'` -' - k, 1- ( ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic e_Actv <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> hn t sac) tc, i '31I S <br /> PHONE PHONE ❑ Site Plan approval from <br /> 6 O g- -2-9 1 4 I applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 5; o 5- S, I/'CI- ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> El ❑ Elevation of property <br /> EL <br /> NUMBER If 710161- 2— 3 . 1 24 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> S 1000-11'04\ ✓8J-(� 1/4: /4/4: El Driveway permits <br /> ADDRESS: (state,county,town) <br /> .c frYl t m P h � ❑ Sanitary permits <br /> CSM: LOT 1 SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: /�� ,7;:' <br /> � i , <br /> -PC Iltel/ <br /> G� C�Gt�Gt i s i <br /> 'This project is a new building or structure. U P ? <br /> ❑This project is an addition/alteration to an existing building or structure. z <br /> SANITARY SERVICE: PERMIT NUMBER: 0 y eSS r„yam <br /> K �� <br /> RISEWER [SEPTIC ew! r�� o) / <br /> HEIGHT IN FEET: _ NUMBER OF STORIES: (Not including basement) °” <br /> 1 . 2-5 We{ e , R 'v plain/ <br /> ,- or d' <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) �� <br /> ,p : <br /> BASEMENT: 1ST FLOOR: <br /> -� ,� l <br /> � <br /> � l!� , TOTAL SQUARE FOOTAGE: , ( t+ *d of i•.a�, <br /> 2ND FLOOR: 3RD FLOOR: <br /> �y <br /> 5�� ,/ . <br /> i w- )s�SUCW : <br /> ESTIMATED CONSTRUCTION COST: Z, " <br /> Please round to nearest dollar) ♦ "♦ ♦ ♦ "♦ ♦ 67600 — ' ` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ERINo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2 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) [1�Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes E No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) ■ -4 <br />