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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS AME <br /> C 1\ t , <br /> OWNE ADDRESS Number,Street, State,Zn� r S ❑ Zoning us; CUP; <br /> r D estriction;CSM <br /> 1303 4a, Foi l_ c-71 e. l� Ho <br /> lance(# ) <br /> HO PHONE CELL PHONE E-MAIL ADDRESS <br /> ` <br /> -Ji(P Cigq3 Si Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR AME <br /> Ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRES of well/septic <br /> (City,State,Zip) kk (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site Plan royal from <br /> applic a towns <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 lour ans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.w Lus/) Elevation of property <br /> PARENT PARC LNUMBER: CURRE TZONI G: ACRE tp://accessdane.co.dane.wkEu.s/) P y <br /> ❑ PARCEL 0661 ` 0 / %9S' tr) frontage drawn to scale. <br /> NUMBER v�J 11 ( � (�//G�/7N� <br /> TOWN�bH� d <br /> �� ' CTI p: /4 1 ` C ❑ Drivewa rmits <br /> _ '� (7 ' 1� '/4'/4: NS 1 Oun <br /> ADDRESS: l Rc) (Stat ty�t0 <br /> / 563 L <br /> fQ 4 �e ❑ Sanita ermits <br /> CSM: OT SUBDIVISION BLOCK/LOT (p C,private) <br /> PROPOSED PROJECT INFORMATION TAFF-REVIEW . <br /> PROJECT DESCRIPTION:. G _y <br /> /r t 4-G d r- 5iii4 ?o),e (�:r n : K J C amt.-District 1 WI-Cis project is a new buildi g or structure. g Permitted Use? <br /> ❑This project is an additio alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 'Rim ` <br /> ❑SEWER SEPTIC (new/ istin• *Y' <br /> HEIGHT IN FEET: r NUMBER OF STORIES: (Not including basement) a <br /> 1 +'z) 0 i)v ix 4 is <br /> 5h r a I rid t -.S ent) <br /> AREA TO NEAREST SQUARE FOOT: 3 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) . <br /> a a a {n t <br /> BASEMENT: 1ST FLOOR: � ,� <br /> 6 ' J 51 l TOTAL SOUARE FOOTAGE: -?� '° + E 4,7,1*, ' <br /> 2ND FLOOR: 3RD FLOOR: l.� 11 3` � N ' <br /> Review I + Survey f_ <br /> ESTIMATED CONSTRUCTION COST: ...... -.► _+ -� /5 () and'availabl e� s. <br /> (Please round to nearest dollar) <br /> J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 0 / ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ,❑,Yes l_7 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? l�Yes ❑0 NNoo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 2"No <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank pone) <br /> one) <br /> 6. Is a location survey required? (see reverse) ❑Yes ffNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) on Back) -♦ -+ -♦ <br /> (aroa) <br />