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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 /> .fie 11(�' wcAc �5 ❑ Zoning Status;CUP; <br /> OWNER RAADDRESS (Number,Street,City,state, r�p f�✓1v} Deed Restriction;CSM <br /> HOME PHONE PHONE � , `E-MAIL, ADDRESS��� Variance(# ) <br /> a% ,,,-49-2 .-11.00\C9-0 ' 4eS•C *M ArSite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> .,_ACg Wel; <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR "DRESS of well/septic <br /> • <br /> , <br /> (City.Stat )_ (City,State,Zip)/h►v 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.wi.us/) levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL 0 b 11 1-) `1 96 /05 R_ 314, frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/: 1/1/: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> P-I ? ' I a1 s-- NOTZ_ GA}2g,J !Z O ❑ Sanita <br /> CSM: LOT SUBDIVISION BLOCK/LOT ry permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION _ <br /> PROJECT DESCRIPTION: ,. � »�-„ , . <br /> nn (J <br /> . ❑This project is a new building or structure. V.2.-f_1446±6_,;240,, <br /> . <br /> 4-T-his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: , - e a _ p r - x :;.„` <br /> ❑SEWER ❑SEPTIC $ ' 3- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) 5:i°-.",-;:_,< -,¢ fi <br /> AREA TO NEAREST SQUARE FOOT: : q �; - �` <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,, ' �� <br /> BASEMENT: 1ST FLOG rf la:IrilOgli <br /> 4, TOTAL SQUARE FOOTAGE: 4. 4.'°:•-•:4'11. � <br /> 5- 41 ® , � ; <br /> 2ND FLOOR: 3RD FLOOR: 4- /I- 0 . <br /> ESTIMATED CONSTRUCTION COST: Q ` ,; s: <br /> (Please round to nearest dollar) ♦ ♦ ♦ "'� ♦ "♦ 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes 1.No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes fallo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ❑No <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) =,/ (Continue on Back) —► -i <br />