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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OVr NAME <br /> Li' �X-7-- ❑Zoning Status;CUP; <br /> OWN ADDRESS um• { t,City, - te,hp) \ t I Deed Restriction;CSM <br /> 5 �V�J C1/4. r\ •.i. VC` \ ,S Y Variance(# ) <br /> HOME PHON CELL PHO i E • ADDRE <br /> 'Q _,, 1- , •ib. ;4 _ N ‘ 1 U Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR tiAttl <br /> S Z El Site Plan including location <br /> AGENT ADDRE 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-MAIL ADDRESS E-MAILADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:!/accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT •1 RRENT ZONING: <br /> ID PARCEL KIMIIII frontage drawn to scale. <br /> NUMBER • aNii' Ilk I,- ..• <br /> TO HIP: SECTI• ❑ Driveway permits <br /> \C — '/`: '/'/`: ,S--- . (state,county,town) <br /> ADD ISS: <br /> . v 3 ��1 t er0 %': ION BLOC 0 3q ❑Sanitary permits <br /> o ` nn o ` (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF <br /> PROJECT DESCRIPTION: <br /> AV1..1 • it:t 111 •_ Mk.* 1. • . • ❑ Zoning District <br /> . E is project is a new building or structure. ❑ Permitted Use? <br /> ['This project is an addition/ Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER U RtIfai Address <br /> FEWER EPTIC �1 gs c ii'�' �0,� (11B�I1i@XI ) <br /> HEIGHT IN FEET: I e NUM__BEtt OF ST IEo: otoicIudig basement) ❑ <br /> �a Sir 1' Shy (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and abode decks or porches) ❑ <br /> BASEMENT. 1 4 1ST FLOOR: 4, TOTAL SQUARE FOOTAGE: ( dam , <br /> 1 g X k40 llllmgfaccess) <br /> 3 FLOOR' <br /> 2ND\5 1 t \ C 4� J V <br /> � � 0.0 Q Review Location 7►1. <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ �� ( , �O and mashie oPbons. <br /> (Please round to nearest dollar) <br /> 1$4loiy i 201\ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? es ❑No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? s ❑No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es o <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 blan none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? DYes No <br /> APPLICATION MUST BE SIGNED <br /> 0 3 <br /> If:nntim.o nn RsrH J J r <br />