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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 /> --./A rn L S k1a 7,b A ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> 4=.S Q a G t ■) A I VG --;z=. 11.2 sT bj4 Variance(# <br /> HOME PHONE CELL PH NN .) E-MAIL ADDRESS M,o■L, <br /> b 8. 2))/-•7y-7I .v.v __ ;. a h k a.zc) a Ci a' ni L.Cd/ ❑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) ❑Setbacks <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wl.us/) Elevation of property <br /> ❑PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: frontage drawn t0 scale. <br /> PARCEL 4.• 09- L�_��33-b �- 3 25/ <br /> NUMBER / '`S i e�c+.uTi �' <br /> TOWNSHIP SECTION: <br /> 1� 3 1/4: N 1,3 4, 1/4%: SE ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> &co? )/■\q .k.K4 -be FcR�s1" t-1- js, �3Ss 2 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> Ak-a ,k4)t„T Po 1-)7y'rrt #E 1414 a✓x>b g District <br /> . MThis project is a new building or structure. <br /> Ci Permitted Use? <br /> ['This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> EWER PEPTIC (neat/ex ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ wetiandinootoaini <br /> AREA TO NEAREST SQUARE FOOT: • i $16.`f S►tent " <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> 2ND FLOOR: 3RD FLOOR: j TOTAL SQUARE FOOTAGE: 4, ( , nce, <br /> ��6) <br /> r- <br /> ESTIMATED CONSTRUCTION COST: Q /b • /' U t �avai***Phons. <br /> utvey arid(Please round to nearest dollar) • W 3�Oe, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes al. ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes n o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Byes U o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes jlo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# / q)1 ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes alo ❑Don't know <br /> 7. Is this to correct a violation? [Yes 0Vo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -e -► <br /> 545-112(4/08) <br />