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. - z,P5q <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER:INFORMATION ._ .,__ -4' ',. t,ig: �;,.,M;: ,.�, . < �., CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 51- V45zik6K <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi Deed Restriction;CSM <br /> / 7 0 �.eX-State <br /> c-E1 /Yk cPN/G✓/ ,r?Cr, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION.;::, - , CONTRACTOR INFORMATION - and includes dimensions <br /> AGENT NAME // CONTRACTOR NAME <br /> �^"t° 4 <br /> i/, 'c ies..� Z.l et—iv/iv 051/5/x/S ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 383 -y* ./ed �A- ,-- • <br /> (City,State,Zip) f3s 1(City,State,Zip) ❑ Setbacks <br /> C�T� S C �sis vLS/ r L'� r.•ME" <br /> PHONE / PHONE ❑ Site Plan approval from <br /> Z z r — g S"o / r,4,44 applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION.;(http:7/accessdane.co.dane.wi.usn; ❑ Elevation o <br /> Elevatif <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> P rtY <br /> ❑ NUM ER LET r&i frontage drawn to scale. <br /> TOWNSHIP: / SECTION: <br /> QS o T �UNA/ IA: +/+/: El Driveway permits <br /> ADDRESS: (state,county,town) <br /> y/7 G'0� 'zw—r ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> FAA roA.A<<< (public,private) <br /> PROPOSED PROJECT INFORMATION. <br /> PROJECT DESCRIPTION: t51 ' <br /> ❑This project is a new building or structure. <br /> This project is an addition/alteration to an existing building or structure. 2 r ' <br /> SANITARY SERVICE: PERMIT NUMBER: . r `� F..� ' (I <br /> �� �t 7 e ai"X`��P,^ri , <br /> ^S <br /> ❑SEWER ❑SEPTIC ,, = . <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �� ' v . ‘ .- <br /> AREA TO NEAREST SQUARE FOOT: 1 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) n <br /> BASEMENT 1ST FLOOR: � ®� li4ao r�� <br /> t <br /> 4, TOTAL SQUARE FOOTAGE: 4, • $1,, 1" ,,, <br /> t� <br /> 2ND FLOOR. 3RD FLO R: ` ter . ` <br /> 7R' err '" .- <br /> S d ept ,' b€ <br /> ESTIMATED CONSTRUCTION COST <br /> i�a ro o�� V <br /> (Please round to nearest dollar) ♦ "� '♦ "♦ �SO U m <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes KiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 No ❑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 A 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) lifYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(406) <br /> (Continue on Back) —► —► —0 <br />