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ZO(IING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION COST ER TO PROVIDE <br /> OWNER NAME <br /> OWNER ADDRESS (Number,Str i ,s oning Status;CUP; <br /> Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE <br /> PHONE E-MAIL ADDRESS <br /> Dv‘Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions 6 <br /> AGENT NAME CONTRAC,OR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACOR ADDRESS of W II/septic <br /> (City,State,Zip) (City,State,Zi <br /> ,11,� etbacks S�/ V <br /> PHONE PHONE ite Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> I: or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wri-us/) <br /> PARENT PARCEL NUMBER: CURRENT.ONING: ACREAGE: yCtevation of property <br /> Li NUMBER frontage drawn to scale. <br /> TOWNSHIP: n <br /> S • 0./: <br /> , / i� A A. i it %4: 14a'/a: Driveway permits Q�,k ` i <br /> ADDRESS: - (state,county,t kvn)' <br /> c <br /> CSM: LOT SUBDIVISION BLOCK/LOT unitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> .;;ATAFF RE1('IIEW <br /> PROJECT DESCRIPTION: <br /> ontrtg fltst <br /> ❑This project is a new building or structure. <br /> LertttteJ ? . <br /> ❑This project is an addition/alteration to an existing building or structure. _: �/ <br /> SANITARY SERVICE: PERMIT NUMBER: LI Rt taf�ress /" <br /> ❑SEWER ❑SEPTIC 3 4 e^ ti ) .4 - <br /> HEIGHT IN FEET: <br /> NUMBER OF STORIES: (Not including basement) <br /> - A <br /> AREA TO NEAREST SQUARE FOOT: Sfiot'etar F �thenf) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) " <br /> BASEMENT 2 1ST FLOOR: ( �•'� • �t �� �� it (�(/ <br /> //t�C` (�I-7��I „ TOTAL SQUARE FOOTAGE: 4 1,S fps, g , "z - 1 `'I Fi' <br /> 2ND FLOOR 3RD FLOOR: Or / <br /> jc1ewiocauonsurvey <br /> ESTIMATED CONSTRUCTION COST: and(Please round to nearest dollar) <br /> ♦ ♦ ♦ ''i ' a�j� SFie � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑YY s ❑No lyDon't know <br /> 2. Is there a wetland or floodplain on or near the property? INY s ❑No CI Don't know <br /> 3. Have you talked with the township about your project And are they in agreement'? UYes Li No <br /> 4. Has there been a zoning permit issued for this properly in the past 5 years? CI Yes & o <br /> 5. Is this project associated with a rezone/CUP/variance (petition/appeal# ) (leave blank it Done) <br /> 6. Is a location survey required? (see reverse) ❑Yes IMo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ISAo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► -+ —► <br />