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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> 0.‘, E11.NAME n <br /> JOb4 ' `f' c(L 4-Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> iMYEfl-lf.INE a� Zerir i�.� ���5-�_ Variance(# ) - <br /> CELL PHONE E-MAIL ADDRESS <br /> z ��z or—S�Sc d <br /> 12-Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR AME <br /> nti , e e'5?,-R ,(Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 95Z Sam a <br /> (City,State,Zip) (City,State,Zip) _ 4 Setbacks . <br /> PHONE PHOoPJ o^ �3S�5� M Site Plan approval from <br /> o ff-592- '/ ? applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING:(http://accessdane.co.daAnceR.EwAGLEu:s/) „ levation of property <br /> j NUMBER o221lO3D/6%3-5775--fV 4-/((X)A_zi Pil- 3e �� frontage drawn to scale.PARCEL <br /> TOWNSHIP: SECTION: Ala) ,�y <br /> "DA1/0;' 6/ 1/4: N a) 1/ai/a: 5" 4r Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION "s7 <br /> PROJECT DESCRJFTION: , - �" <br /> his project is a new building or structure. .;: �, <br /> ❑This project is an addition/alteration to an existing building or structure. ',: r <br /> SANITARY SERVICE: ' ` �"` <br /> PERMIT NUMBER: � g � � .: <br /> U SEWER SEPTIC 2 r 3� "ma's ., m <br /> HEIGHT IN FEET: t NUMBER OF STORIES: (Not including basement) ., "' <br /> AREA TO NEAREST SQUARE FOOT: ?�F '�,;, 4 ,„ <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) w� ,, : ' h <br /> BASEMENT 1ST FLOOR: ` <br /> l TOTAL SQUARE FOOTAGE: fi kr .k ' <br /> 2ND FLOOR:! 3RD FLOOR: i O wx r -t A <br /> ROW- /b - . <br /> ESTIMATED CONSTRUCTION COST: = .-, ,a�, & <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ �?n oa , �;-• ' i. : ,- • h' <br /> .. !D1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes *IVo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes No ❑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? UYes . No <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes *o <br /> C, — 0l 44 ci APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ ■ —► <br />