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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER• NAME <br /> ,z .- 4 'fl ' �^'∎5kcxk ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> �..: Deed Restriction;CSM <br /> 843 —71,Q t c r 1.G am �S --'3,CA Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ESS <br /> `b�(r)-1 \s— ZZS-moo 3 C�o.f kl^t c�vS�oC \c.\0c. .11 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wri.us/) ❑ Elevation of ro ert <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P Y <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: 1 t 1 ❑ Driveway permits <br /> 14: 4%: <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION �$' � REVIEW <br /> w r PROJECT DESCRIPTION: $L R ?at,�A <br /> g 1 1 ,'❑E2onir 50 -2c k \a cstv�R <br /> ❑This project is a new building or structure. <br /> ❑ Permitted <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: /Runs res <br /> EPTIC (Ttew/ext5'ting t <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 5f:or r � tf tent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1 ST FLOOR: <br /> fto :::::,1:::,,..:.:;4.,:.:..s;;,71',,,,,;::3 TOTAL SQUARE FOOTAGE: j � ' ~ ' + e- <br /> 2ND FLOOR: 3RD FLOOR: ''+'� � <br /> ESTIMATED CONSTRUCTION COST: y1 °a _ <br /> Ii Review 0.4,,iop Survey- <br /> (Please round to nearest dollar) "� "� _ 'C � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Yes ❑No GI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? .❑Yes CI No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Yes CI No <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) a Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? 1 CI Yes �No <br /> --`7 - GIDI <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -o -s <br /> 545-112(4/08) <br />