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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 /> ` ,O INI tt. S tq ).-)a ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> `7 1 Loy=[ C-1--(:) / -4"Q-- (- tc_L_ \ E-MAIL- ur�t�A�L-tz (,t) 1 535Y7 Variance(# ) <br /> HOME PHONE CELL PHONE E-MADDRESS / <br /> SO\—/613'3 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ■TRACTOR NAME <br /> `J}a�lCi l,�Cic Jc (Z C�j-ly .❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7170 CL-oq • ', A'ILL- 9-- <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE 'DONNE w t ❑ Site Plan approval from <br /> L j --..5-75--/O 3 5 applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane,co.daneawi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER n'5< 2 O /4P41°1-13-1 QZ— l (69Z frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> ❑ Driveway permits 1A1/4:5 Q r= <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> REVIEW <br /> PROJECT DESCRIPTION: <br /> mi ❑ Zoning Distrit�3c to m�1©) l <br /> ❑This project is a new building or structure. © Permitteld Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rurit Address <br /> ❑SEWER )4 SEPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑-wetia> d o N <br /> `' Stioreiantl(attachment) <br /> AREA TO NEAREST SQUARE FOOT: .. <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: <br /> It9tt � <br /> 4, TOTAL SQUARE FOOTAGE: �r ' , ism r <br /> 2ND FLOOR: 3RD FLOOR: f-ti}Itaf�/r1SS� ' <br /> o❑ Lo Survey- <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "� "p "� "p �t , and available ons., <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑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'? ❑Yes ❑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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -0 ♦ —► <br />