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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 1 <br /> Antes <br /> £L4\ r' ! ' k f _ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) l Deed Restriction; CSM <br /> `b.°k O c \0-2�-� , 1 t 1C \q:n . Lo►. S3$6( _ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS ll tA'1' 131-7gri f- . . - ' ' C, (AO.,0o4 0SbC \0L <br /> 106.4. (\ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE - ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL 43LNUMBER: I CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 04iba0 --03.31 w 6 frontage drawn to scale. <br /> WNSHIP: SEC LION: <br /> �A cv V q 1�4: ,itA f 1/41/4: .S ❑ Driveway permits <br /> ADDRE s: (state,county,town) <br /> CSM: (ta© 1 O� �.e ' , 1cr6. i �‘. <36-'ST( ❑ Sanitary permits <br /> LOT SUBDIVI ION (1 BLOCK/LOT (public,private) <br /> S &r A `\5 <br /> PROPOSED PROJECT INFORMATION STAFF <br /> PROD T DESCR TION: <br /> I b LEI 7=Z Ort 4 �°k�. � de ( Zoning }istrict� ,.,,,:,,:„.Imp.,..:„., „.,..1-,;,,,,..:. <br /> . ❑This project is a new building or stliture. ❑ Pe"rmitted`Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addres'sA <br /> SEWER ❑SEPTIC (new/exlsing <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) l` <br /> =❑ Wetlanlaad <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shorotand (off onty <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ` ', <br /> BASEMENT 1ST FLOOR: rOSI{3r< ''ar1 P>wr(11io <br /> /Q x 16- 4, TOTAL SQUARE FOOTAGE: 4, (slopes,distur4 nce,, <br /> °C /� 'fillift/a ess , <br /> 2ND FLOOR: 3RD FLOOR: aC'm <br /> I �© SQ. V I- ❑ Review iL tfot Sunray <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ Q �+►p and aVaitabte Options <br /> (Please round to nearest dollar) $ i 04-0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No Cl 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 /> � <br /> '�f 073 APPLICATION MUST BE SIGNED <br /> 545-112(aroe) v( A (Continue on Back) ■ -o <br />