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I <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> • PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS' ��% <br /> OWNE' DD- SS (Number,Street,C. tat> Zoning Status; CUP; <br /> W/) / rf Q • 1 IF Deed Restriction; CSM <br /> Ul fOrJ`7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 1 / <br /> dp! — i? 575=9500 5-41; L 6 0)C' l R to r/�'lel ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME CONTRACTOR NAB"'E <br /> cT I J e I-F ❑ Si an including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o II/septic <br /> (City,State,Zip) (City,State,Zip) "Setbacks <br /> PHONE PHONE ❑ Site proval from <br /> app' le township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor ns to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) la Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P y <br /> ❑ ur-f /0 et// S.i nn 1 --/f�- -- S -� frontage drawn to scale.NUMBER <br /> TOWNSHIP: JJ: 1 1/41/4: rl permits <br /> L SEC II / /4: N E �4�4: iv k./ ❑ D <br /> stat- .un <br /> tY,town <br /> town)n�/Y�g S <br /> San -. permits <br /> CSM: oiih SUBDIVISION BLOCK/LOT (p • IC, • ivate) <br /> PROPOSED PROJECT INFORMATION IV '':STAFFiREVIEW <br /> PROJECT DESCRIPTI � � 1 ' / <br /> tirtceX re-. -PA-Pr0,4 t istr►etx <br /> . aThis project is a new building or structure. <br /> .p ermlttec Uses <br /> ❑This project is an addition/alteration to an existing building or structure. '� "• <br /> SANITARY SERVICE: PERMIT NUMBER: � f Ur ° t, <br /> ❑SEWER ❑SEPTIC n /eisng) a <br /> HEIGHT IN FEET: I UMBER OF STORIES: (Not including basement) 4 <br /> j e"\ I W '�I ► ❑ Wetland/Fioodpi a <br /> AREA TO NEAREST SQUARE FOOT: <br /> •®V ttachme <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or p• ches) <br /> BASEMENT 1ST FLOOR: <br /> ❑ Erdeton ntfatpern)! <br /> (Slop distrb nce, �i�() j TOTAL SQUARE FOOTAG is, u <br /> Mlling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ) G C) 0 <br /> ESTIMATED CONSTRUCTION COST: -�► --► $ and avalleb Options <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes a No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes erNo LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes allo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes erNo <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 4.610 ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes YJ No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► —► —► <br />