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- - ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION <br /> OWNER ME CUSTOMER TO PROVIDE <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> L1 5 /hy�- RI (Awe i'i .s.,Z 7 <br /> Deed Restriction;CSM <br /> HOME PHONE CELL PHON E-MAIL ariance(# ) <br /> 1/$1-- 2-9o74 _ -MAIL ADDRESS <br /> AGENT INFORMATION CONTRACTOR INFORMATION CI and Plan drawn to scale— <br /> AGENT NAME and includes dimensions <br /> CONTRACTOR NAME <br /> AAlsrlccti.-t klirgr/le_/3&,.//he-5 Janes <br /> AGENT ADDRESS ❑ Site Plan including location <br /> CONTRACTOR ADDRESS of well/septic <br /> 5-742 L,'r,i erJ Dr�. SH.,pel;.►e <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> S.." P•~,r,' iv/ 5 5-170 <br /> PHONE PHONE ❑ Site Plan approval from <br /> l9(1- gw/11713 applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Crl `e ` r✓ ao/• to-r.' — ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL <br /> NUMBER 20 frontage drawn to scale. <br /> TOWNSHI SECTION: <br /> el <br /> `e-���s.k. D y '/a: St wh: S CI Driveway permits <br /> ADDRESS: /� <br /> q 575 �r KI/ h/el county,town) <br /> y LOT � � h/el W/ -5-3 S.�Z ❑ Sanitary permits <br /> CSM: SUBDIVISION BLOCK/LOT ry p <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION:/ <br /> <I—a' _4 _, ■ s t -€ <br /> • At This project is a new building or structure. e- , � $� <br /> ❑This project is an addition/alteration to an existing building or structure. -% , v <br /> SANITARY SERVICE: PERMIT NUMBER: tfz 0 > '."- : <br /> ❑SEWER ASEPTIC VA <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) b <br /> AREA TO NEAREST SQUARE FOOT: r r- '` <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) --, ' <br /> BASEMENT: 1ST FLOOR: ® s :vfi <br /> N/U4 TOTAL SQUARE FOOTAGE: f aih <br /> 2ND FLOOR: r <br /> 3RD FLOO // a t s-, <br /> ESTIMATED CONSTRUCTION COST: � � � <br /> -► -► --► ' -► -► "� <br /> (Please round to nearest dollar) 000,2 , 1 : s a ; ,� <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 I 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 Li Don't know <br /> 7. Is this to correct a violation? Cl Yes 4 No <br /> APPLICATION MUS BE SIGNED <br /> 545112(4/08) (Continue on Back)T -► -► -� <br />