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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 /> 1i( p Zoning Status; CUP; <br /> OWNER ADDRE,SS\`Num.er,Street, ity,State,Zip) Deed Restriction; CSM <br /> 3241 phi, Tr Ore A l....ir 5357 5 Variance(# ) <br /> HOME PHONE CELL PHONE -MAILADDRESS <br /> (o(�-�C�S � l .3• .i 44) Ite Plan drawn to scale <br /> 'AGENT INFO_ RMAT_ION , CONTRACTOR-INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ejy1CPlan including location <br /> AGENT ADDRESS CONTRACTO DRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> _......2‹ <br /> PHONE . PHONE ❑Site pproval from <br /> applicab township. <br /> E-MAILADDRESS E-MAILADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.Et.us/),us/);: . ❑ Ele io f property <br /> PARENT PARCEL NUMBER: CUR TZONING: ACREAGE: <br /> ❑PARCEL R --)N i' fro drawn to scale. <br /> NUMBE a � c) <br /> I 0 I 1 p 0 0 S ' <br /> TO HIP: SEC l0 <br /> �V\✓1 '/a: N \J 1 alit: ❑ DAou5ntyown) <br /> ermits <br /> ADDRESS: \ 1 i Il 1 (s <br /> �� a C1 �'" ",./I Q C,�I� ��l ❑Sanit ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT C, rivate) <br /> - • -co,, �� 5 1O <br /> PROPOSED PROJECT INFORMATION STAFFS REVIEW <br /> PROJECT DESCRIPTI N: <br /> �e6 I ) Q X'-o z In District <br /> k, xhE T � <br /> . ❑This project is a new building or structure. - rmltted_Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NIINJ7 <br /> Rural o• ss <br /> FIEWER EPTIC ' /, (new s in• <br /> HEIGHT IN FEET: NUMBER OF ORIES: (Not including basement) { ' <br /> We • Flo.• m/ <br /> AREA TO NEAREST SQUARE FOOT: ShoT achment)- <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FLOOR: ® E[OS10 •r1trol • rrllt <br /> �O O 4, TOTAL SQUARE FOOTAGE ,, s1op s • 'd•ahce, <br /> ) q`er ccess) -Ef -. <br /> 2ND FLOOR: 3RD FLOOR: 7 r' °4 a <br /> Q� Re iieW ®catlo a Survey' <br /> ESTIMATED CONSTRUCTION COST: $ (c, and avt4 `• soptIons <br /> (Please round to nearest dollar) �"� ♦ --► ♦ ♦ --► . <br /> / jr <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes qJo :Pon t know <br /> 2. Is there a wetland or floodplain on or near the property? Elves ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? _ Yes ❑ o <br /> 4."Has there been a zoning permit issued for this property in the past 5 years? :Yes -INN o . <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 JNo ❑Don't know <br /> 7. Is this to correct a violation? Eyes JNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ --► -♦ <br /> 545-112(4/Os) <br />