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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> NER NAME (� <br /> N.O0(14� (3. L5�� Zoning Status; CUP; <br /> O NER ADDRESS (Number,Street,City,State,Zip <br /> eed Restriction; CSM <br /> II a 7 1 1.AJ • 54.1% w.�1 d� R Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6 0631 ? - Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS well/septic <br /> (City,State,Zip) (City,State,Zip) acks <br /> PHONE PHONE 'ite Plan approval from <br /> plicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) I., levation Of property <br /> PARENT PARCEL NUMBER: CURREN ZONING: ACREAGE: <br /> LI NUMBER 5 ( '-f}(_s 4 O / -- ( e> ontage drawn to scale. <br /> TOWNSHIP:.., r .,v L SECTION:1T�ON: <br /> D 1 ,/ 1 1 �� Driveway permits <br /> _ .--. /a: /a/a: - ( te,county,town) <br /> ADDRESS: y n ��F <br /> ) '"� 1 C,C)- 1 p�^ !C Sanitary permits <br /> CSM: •T SUBDIVISION BLOCK/LOT <br /> ublic,private) <br /> PROPOSED PROJECT INFORMATION !;STAFF REVIEW-( <br /> PROJECT DESCRIPTION: <br /> s ,-e) c �S'-G Wing f tstrict <br /> . - his project is a new building or structure. Jermltted Use?- <br /> ❑This project is an addition/alteration to an existing building or structure. j <br /> SANITARY SERVICE: ., PERMIT NU � ` ra t4ddress <br /> U SEWER XI fii€PTIC W 65,, <br /> HEIGHT IN FEE \ NUMBER OF STORIES: (Not including basement) <br /> C� 1l eflan few•ilawij <br /> Shor : attachment <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST OOR: ''.1' ,:,22,,,,,,,,r.9 I; S10 e1:"9 ermlt g <br /> t I 4, TOTAL SQUARE FOOTAGE: slopes 4t rba,nce, <br /> "I filling aced <br /> 2ND FLOOR: 3RD FLOOR: ��� Y£, a <br /> k3 3 <br /> C] Revie ' oc ott Survey.. <br /> ESTIMATED CONSTRUCTION COST: $ `� and anal [e options 2 <br /> (Please round to nearest dollar) ♦ --► ♦ ♦ --► -i ) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 'lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 35kNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 29 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? ayes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />