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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY GMINER INFORMATION'i't F44.: :, ,;,:: CUSTOMER TO PROVIDE <br /> OWNER NA - � <br /> OWN RADDR SE S (Nu b ,Str. t,City,State Zip ❑ Zoning Status;CUP; <br /> �� 9 Deed Restriction;CSM <br /> �6 CJL Variance(# ) <br /> HOME PHONE CEL .•NE E-MAiCADDRESS <br /> 83 5/9 9 �O-C/O 9d ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR:INFORMATION: and includes dimensions <br /> AGENT NAME CONT-• TOR NAME <br /> /� &%- 4 / 4r , ❑ Site Plan including location <br /> AGENT ADDRESS •1 -r• •- •By:-ES !;se of well/septic <br /> (City.State,Zip) (Cly,State,Zip) • ❑ Setbacks <br /> PHONE PHONE / ❑ Site Plan approval from <br /> 02a l-e9 cPS/ applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION'INFORMATION (http://accessdane.co.dane.wiass/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • <br /> 'A. '1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION R 4 I a ` LEA •: <br /> PROJECT J SC•IPTI r: / / <br /> k ! � fi F � 3-4 - �' AL-. 4v. 11 <br /> pa This project is a new buil.tng or structure. a , ' ' <br /> Y tr '' ems.£ <br /> ❑This project is an addition/alteration to an existing building or structure. � ,i.:1; =s ��1 <br /> SANITARY SERVICE: PERMIT NUMBER: f.'s A. ' -'i r4 ,:lil <br /> ❑SEWER SEPTIC p_ ai ` : - <br /> HEIGHT IN FEET. NUMBER OF STORIES: (Not including basement) x . to$ <br /> AREA TO NEAREST SQUARE FOOT: 1, <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) `'° A w } <br /> � . �� r <br /> BASEMENT: 1ST OOR: S �° � 4' + T s� <br /> 1 TOTAL SQUARE FOOTAGE: 1 H:31 „r a �„C5 r �a <br /> , <br /> 2ND FLOOR 3RD FLOC/- '�"q( t s <br /> ' ' ' `ESTIMATE; ONSTRUCTION COST --- '''''.'-':',..',!9-::.1A <br /> U O O a(Please round to nearest dollar) a k <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 0 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? cgi Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? J Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? gj 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 f No <br /> APPLICATION MUST BE SIGNED <br /> 545-112 4roe {Continue on Back) -► -► <br /> ( ) <br />