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• ,r <br /> NY:::.l <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENTto Web-App# <br /> PROPERTY OWNER..INFORMATIONq _: • N=00 °;, ,-.,_:< 1''P;'-'1.--.111:' CUSTOMER TO PROVIDE <br /> OWNER Nfie7+• g+ L'''''Do ` It I r ❑ Zoning Status;CUP; <br /> OWNER AS Number,Stre t,City,State, I( y � Deed Restriction;CSM <br /> 22 • °Y l/" 3 55- Variance(# ) <br /> HOME PHONE ELL PHONE -MAIL DDR <br /> 6 e• t' 35"3 O .0. 23 ✓ ‘ • I ; t ti 1"7,41 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION -;:> CONTRACTOR;iNF.ORMATIOPd`= ;,, _ and includes dimensions <br /> AGENT NAME CONTRACTOR NAW, <br /> 11 �A o .�e If—it 14 i` I t <br /> )- ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <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:llaccessdane.co.dane.wLus/),' <br /> PARENT PARCEL NUMBER: CURRENT Z NING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0 coq-061—WO • /Ei 3E3 frontage drawn to scale. <br /> NUMBER V UU <br /> TOWNSHIP: SECTIO ❑ Driveway 0 I� 1/: 1/1/4: y permits <br /> ADDRESS/ (state,county,town) <br /> • <br /> (,22 � ce f cc- Or,-6)-1 �' �35 ❑ Sanitary permits <br /> CSM: LOT SUBDIVIS BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION <br /> Lea,,,, X3 -6c4d � <br /> This project is a new building or structure. ' • :!,-=;:--,,_ <br /> �tjd <br /> ❑This project is an addition/alteration to an existing building or structure. i• <br /> SANITARY SERVICE: PERMIT NUMBER: °°I- k i fa <br /> N Pi �� tr . <br /> ❑SEWER ❑SEPTIC Q r <br /> HEIGHT IN FEET: NUMBER OF STORIES: of including basement) 2 - w , ; <br /> 2 �zj <br /> AREA TO NEAREST SQUARE FOOT: i `° t x`147= <br /> � � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' r M� <br /> BASEMENT: 1ST FLOOR: * ' �e a R w � r ��, TOTAL SQUARE FOOTAGE: 4,2ND FLOOR: 3RD FLOOR � <br /> ESTIMATED CONSTRUCTION COST: ��� �� <br /> ( ) --0 --0 --0' .4. --0' —► o -aa . d iii <br /> Please round to nearest dollar ♦ <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 ( 1 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes LI No Ct � 11 <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? `►Yes ❑No -f U hctnc�/ n©'1 ,4 • <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 .t'lo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 6No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* —► - <br /> 545.112(4/08) <br />