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pox_ 0-7s fSo '°r 4-47, -� f2` 1 0 > j <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street te, i ��/ _ deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE , ,, CELL PHONE E-MAIL ADDRESS <br /> 1-7 11-160 • Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS �j / of well/septic <br /> (City,State,Zip) (City,State,Zip) l4�J/I/ Setbacks <br /> PHONE PHONE Site an proval from <br /> applic e township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> M loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> le PARENT PARCEL NUMBER: CURRENT ZONING: A EAGE: le -`' �'• operty <br /> El PARCEL rontair-.. n to scale. <br /> NUMBER /' <br /> TOWNSHIP: TION: A--e r Wa ermits <br /> tOWn <br /> /0�t 4• tf41/4: to COUnty ) <br /> ADDRESS: ---7).. " (� <br /> , Sanit ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pub rivate) <br /> PROPOSED PROJECT INFORMATION ;STAFF REVIEW <br /> PROJECT DESCRIPTION: . / �S <br /> r. ! ,..... <br /> �i'Q xS0 ��°S�jC)\( (Qj( , , L(tfflrg IIisir �;�<_j! <br /> 0 This project is a new wilding or structure. r <br /> ermttted lfs0 <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ' e-5- re.s <br /> ❑SEWER ❑SEPTIC (ne '$ sting <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> V _ 7` :ShorelandFment)x <br /> AREA TO NEAREST SQUARE FOOT: - <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �� att a , <br /> T.c TOTAL SQUARE FOOTAGE. 4 , 000-$.,cf ° e r s.�" 0 i( <br /> 2ND FLOOR: 3RD FLOOR: <br /> `ftlfing/actess tv <br /> Review L1 atl ,ey <br /> ESTIMATED CONSTRUCTION COST: " <br /> (Please round to nearest dollar) ♦ ♦ ♦ -♦ "♦ �� c.‘ �)Q a(1L a vaiI''able o itio is. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? �0 Yee 0 No llrpon't know <br /> 2. Is there a wetland or floodplain on or near the property? l�U,' 9, ❑No El Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? lll�Yes 1;i Nomo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 0Yes QNo <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank) none) <br /> 6. Is a location survey required? (see reverse) 0 Yes UNo ❑Don't know <br /> 7. Is this to correct a violation? 0 Yes 91qo <br /> TIUS <br /> (Continue APPLICA on ON BacMk)T BE 1- SIGNED♦ -i <br /> 545-112(4/08) <br />