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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME .77 ,�Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) `� <br /> eed Restriction;CSM <br /> q'7Z f7w V / 3 8 f I. Variance(# ) <br /> � a rc.,.sc� <br /> HOME PHONE CELL PHONE E-MAIL AD RE SS <br /> F $7 3 -, b-77 -/7os 'Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> N Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE 'Re Plan approval from <br /> applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.cU - , - ) Elevation of property <br /> PARENT PARCEL U CURRENT ZONING: ACREAGE: ( P P rty <br /> El NUMBER SI} - .C"3 ) O G J ./►� frontage drawn to scale. <br /> TOWNSHIP: SECTION: / <br /> A ( la;q 1.-` 7 7 1/a: 5 141/4: c L-' Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT i'l San' :.= -- its <br /> Alb?b.. Co,r•.Co.•0\n V 1-,;- - \ <br /> (pub <br /> PROPOSED PROJECT INFORMATION -:STAFF REVIEW' <br /> PROJECT DESCRIPTION: f_ <br /> C0 - - 1•c ,''', \„)oo/P�-.o): ,- -9 x 6.c) ,'zoning District a. <br /> 0 This project is a new building or structure. Permitted use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: r I Addre ss <br /> ❑SEWER O'SEPTIC - xlsting)a -z <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> h® - <br /> AREA TO NEAREST SQUARE FOOT: tteTtt�`- <br /> 4 <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: a.a# a ,? <br /> '"7'. O Q 4, TOTAL SQUARE FOOTAGE: j (lop , , . ' `+zap <br /> 2ND FLOOR: 3RD FLOOR: = / <br /> ut oo 9 go 1347-44?vi, , . e, ' <br /> ESTIMATED CONSTRUCTION COST: and -, - t ln5 <br /> (Please round to nearest dollar) ♦ -► ♦ ♦ ♦ $ 5 Z C- e„--26.) - , <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes tikNo ❑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'? DYes "No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 2Jo <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 a(`Jo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes l No <br /> APPLICATI MUST BE SIGNED <br /> 545-112(4109) <br /> (Continue on'ON Back) ♦ —► <br />