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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVID <br /> OW AME / <br /> �!/ Co P r / A Zoning Status;CUP; / <br /> OW ER DDRESS Nur�M1 treet,C9tate,Zip) , <br /> Deed Restriction; CSM f O i 6 h ( � Y Q t� () IA S ?�lj Variance (# ) <br /> HOM PHJdN- �, �r CELL PHONE E-MAIL ADDRESS <br /> 3S4Y (Jy( ! Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 4Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of hose IC„ 5 Ai.2/0 <br /> (City,State,Zip) (City,State,Zip) ICA Setbac s � <br /> PHONE PHONEite Plan approval from / V - <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS ( <br /> P Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> %Elevation of property <br /> PARENT P CELNUM¢� CURRENTZO NG: ACREA E: p p y <br /> u PARCEL ��//r 1 l_ 47 �?� �� �� frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: /' SECT �, / � <br /> C _ 0 &/� 1/4: it 6 1/41/4: � Driveway permi <br /> ADDRESS: (state,coun Or <br /> 3 3 / �1/�0 .k S/,, ej <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary •- •I tS <br /> / (public,1, ' <br /> PROPOSED PROJECT INFORMATION STAF sREVI = ;;''' <br /> PROJE,cy DES RI-T/N: / ` / z s <br /> I) S ��Gt ✓ ��j� �j Zoning District �- <br /> . ❑This project is a new building or structure. � ` <br /> i <br /> p f g „�Permi 9d Use?�A� ' <br /> ❑This project is an addition/alteration to an existing building or structure. , -�" { <br /> SANITARY SERVICE: PERMIT NUMBER: I1.t§Kura ' ® esSl Aa <br /> ❑SEWER 4 SEPTIC (new xis , ® ��•i s <br /> HEIGHT IN FEET: /� - NUMBER OF STORIES: (Not including basement) - / r '� <br /> (uJ / Sh relandloodplainl <br /> '..51*( 0 ci at acfime TI <br /> P.%TO NEAREST SQUARE FOOT: tr ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ' s <br /> BASEMENT: 1ST FLOOR: ®�� E�QS1Qn�OntroCper�nt <br /> �� TOTAL SQUARE FOOTAGE: (slo}pes,,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 4, <br /> / `� 4, 5filling/access) <br /> �(� li A W <br /> �Revtevyjl'vcai tort Surue}� <br /> ESTIMATED CONSTRUCTION COST: l `' and avat(able�options ; <br /> (Please round to nearest dollar) --► .4. . <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? DYes ❑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 /> 545-112(4/08) (Continue on Back) —0. —► —► <br />