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• <br /> s <br /> ZONING PERMIT APPLICATION www.count ofdane.corn SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME ` <br /> 1O0( v Y e` <br /> --�eeZoning Status; CUP; <br /> OWNER ADDRESS (Number,SS{eet,City,State,zip eed Restriction; CSM <br /> 1-4 ) 0 I o cl 2 v FL)* Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> c15-7 - 6c71 S . AI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> XSite Plan including location <br /> AGENT ADDRESS CONTRA DRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ,Setbacks <br /> PHONE PHONE ite Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 2 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ■ levation of property <br /> PARENT PARCEL NUMBER: CURREN ONING: ACREAG. <br /> ❑ PARCEL Q I �0 ,�i;111 *! lb / frontage drawn to scale. <br /> NUMBER Q O <br /> TOWNSHIP SECTION: y wa ermits <br /> ?-N) I 1%: 1,4/a: (stat nty,town) <br /> ADDRESS:1 <br /> 1/� 1 0 P r' 0`'t ❑ S ' a ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> -V\ / Z �(pu 'c, 'vate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5/�� X (n oning istric , ,,c <br /> 03 <br /> . ❑This project is a new building or structure. errriitted Use? ... . <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ RUr •a ss <br /> ❑SEWER ❑SEPTIC (;ew/exl <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ Wets •/ ••dplain/ <br /> SFror ' •� (attac meat) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �ro$t°n � col errtt <br /> O C) j TOTAL SQUARE FOOTAGE: j (Slop r ®Isturbance,� `, <br /> .fills g/a•,ess} i fit. <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review '• •• Survey <br /> ESTIMATED CONSTRUCTION COST: a ® e l`e options <br /> (Please round to nearest dollar) "'∎ --► --► -► --► $ (�s ,a. . -::'5:2,,.---,,,,.....,,,p4:- <br /> a�f w <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes allo ❑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 o <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 o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -∎ <br /> 545-112(4/08) <br />