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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O' NER NAME <br /> n3 )A t A C 1-F-- S Zoning Status;CUP; <br /> /WNER ADDRESS (Number,Street,City,State,Zip) eed Restriction;CSM <br /> 12H Bc.„ , (& d/ S..- P�,f.c Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> 5-G6- S i,i - 7$-;`j L_i N' '-1(4 H b r. .-,c,i .c—'-- E Site Plan drawn to scale <br /> AGENT INFORMATION 1 CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> (City,State,Zip) (City,State,Zip) 77 112 .- f.ckS <br /> PHONE PHONE • Ite Plan a.. • rom <br /> applicabl= •wn ip. <br /> E-MAIL ADDRESS E-MAIL AD ESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ►: Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: j,-.el II w <br /> D PARCEL IQ — frontage drawn to scale. <br /> NUMBER OSls f c�"i l—1? 2- �Y 11-7 1 o� S fS`� <br /> TOWNSHIP: SECTION: <br /> C� l c� 1/a: 1 `ti 1/4 1/4 ti -a Drivewa its <br /> (state u ,town) <br /> ADDRESS: <br /> 12— Y R=.r(ei K c/% <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanita • mits <br /> 6 3 l (pub' , rivate) <br /> PROPOSED PROJECT INFORMATION <br /> STAFF REVIEW <br /> PROJECT DESCRIPTION: > - ;. <br /> !�dpi .t reic.,ecY de e k -As ) s - - 13 e d Ax:- �' �� _S Zoning I/st'riat 4� <br /> ❑This project is a new building or structure. j4 Permitted Use?:; <br /> ;=This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: -1 raf A s:, `• r" <br /> ❑SEWER ,-SEPTIC ( c /existing 7, d <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Z "` (-. c2r J rp,...d -d t C� 1 <br /> )10'We 0 ° •�n/ _ <br /> S-.• r: <br /> •A i ment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) , <br /> BASEMENT 1ST FLOOR: ea 0 <br /> :n a ®; { a ' tn..TOTAL SQUARE FOOTAGE: <br /> 2ND FLOOR: 3RD FLOOR: <br /> � <br /> ' Rev' _v ,�SIrvey- <br /> ESTIMATED CONSTRUCTION COST: arida -: • <br /> (Please round to nearest dollar) ♦ '"+ '♦ ♦ ♦ ■ $ Z $GZ% <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes , o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? U Yes `—',NNmoo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Et. ---es 0 N�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 blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes0,UN" ❑Don't know <br /> .W <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -0- <br /> 545-112(4/08) <br />