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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> o R NAME <br /> IZEG-r `✓ LC(4- oning Status; CUP; <br /> ____\) OWNER ADDRESS (N mb Street].City,State,Zip) Deed Restriction; CSM <br /> G 7 11F' r Nail( /13 LF EIn/i r( E t✓% 3 5 t er <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MA LADDRESS <br /> %1$ciLti DAIS &p "2°fc) 7 J VE`� w AA IA 460 „ e Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and incl s dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> e Plan including location <br /> AGENT ADDRE' CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) S acks <br /> PHONE PHONE ❑ Site a oval from <br /> a township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> [ oor plans o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El tion of property <br /> PARENT PARCEL NUMBER: CU ENT ZONING: ACREAGE: p p y <br /> ElPARCEL p c� /� rontage drawn to scale. <br /> NUMBER of�R 136 if-4S D 3��'o 4 -1-i^ it t 5-/_ <br /> TOWNSHIP' SECTION: <br /> Vt Cli / l/ `/� Al '/4: 5E 1414: 3e/f/ (state, permits <br /> ADDRESS: c state, count ,town) <br /> G 7 3 5— l '3 Itary permits <br /> CSM: L SUBDIVISION BLOCK/LOT <br /> • cyaq (public, private) <br /> .. ....... ... ......... ........... ....... ... .. ... <br /> PROPOSED PROJECT INFORMATION S F REVIEW <br /> PROD T DESCRIPTIO ' <br /> S R 41d.,s w/O-ec lc oning District <br /> . This project is a new building or structure. ermitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> ANITARY SERVICE: PERMIT NUMBER: al Address <br /> EWER EPTIC (new/ xistln e <br /> HEIGHT IN FEET: / `( NUMBER OF STORIES: (Not including basement) <br /> D " <br /> lJ ❑ Wetla oodplain/_, <br /> AREA TO NEAREST SQUARE FOOT: Shore1- (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ E osi•, • rot permit <br /> I1 ----S—( 3'` 1 TOTAL SQUARE FOOTAGE: ,j (Stop , sturbance, <br /> I !.,::.57, - ) <br /> 2ND FLOOR: 3RD FLOOR: ��� , <br /> evlew Location Survey <br /> ESTIMATED CONSTRUCTION COST / <br /> and availabl pfi0ns. <br /> (Please round to nearest dollar) ♦ --► $ <br /> /1/D <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes giNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes EiNo ❑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 ON <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 ❑Don't know <br /> 7. Is this to correct a violation? [Yes g]No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —0. —► -♦ <br /> 545-112(4/08) <br />