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ZONING PERMIT APPLICATION wvw.countyofdane.com ,SUPPLEMENT to Web-App#
<br /> PROPERTY OWNER;:INFORMATION' .:.'; _,;;; '4. - ;0;� ' . ,.r._; ;1 - : CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> Jc ,.) 0`2 r`' ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) 1 Deed Restriction;CSM
<br /> /qzo /. ,'ok..- "Pc/Ae , S� ti ; 44-J 535-S? Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> v.pa-a tS' 2 e- 3'me- r day v �45-)1c .CvIM ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION.-.:; , 2 CONTRACTOR:INFORMATION' ., and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<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 /> LI Floor plans to scale
<br /> PROPERTY/LOCATION:INFORMATION.:(http:l/accessdane.co dane.wi.usn ? ''' ❑ Elevation of ro e,�`
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p P '`7
<br /> ❑ PARCEL eid y�61Q _ l/dr _Y
<br /> NUMBER , ,9 7 frontage drawn to scale.
<br /> TOWNSHIP: SECTION: ❑ Driveway-04,n +/4. +/+/4. y permits
<br /> ADDR//E��SS: / `� (state,county,town)
<br /> l'7 441, J 1 i c,i, S3sR ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> PROPOSED PROJECT INFORMATION, - ' T
<br /> PROJECT DESCRIPTION: t.{, `" q
<br /> a
<br /> /� ✓ B - - 4
<br /> ®This project is a new building or structure. l s . .. k ,: -P
<br /> ❑This project is an addition/alteration to an existing building or structure. K -:7 ,
<br /> SANITARY SERVICE: PERMIT NUM=ER: 9 ���_
<br /> e a `
<br /> ❑SEWER ❑SEPTIC /11 cZ l`f 1 � �``
<br /> HEIGHT IN FEET: V NUMBER OF STORIES: (Not including basement) ,t-:?-- „ , ,' 1
<br /> AREA TO NEAREST SQUARE FOOT:
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � w e,Err�
<br /> t BASEMENT: 1ST FLOOR: . a `at m a
<br /> , t/Gk l9 4, TOTAL SQUARE FOOTAGE: `u �
<br /> 2ND FLOOR: 3RD FLOOR: — /X) - ,' f ,j
<br /> ESTIMATED CONSTRUCTION COST / e140,1Ww.14.4Maiat45-,--tg:_1,-,
<br /> `" �g#(Please round to nearest dollar) '♦ -i --► --► "+ "♦ $ 4 coe, -- z
<br /> •
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ,e1 Yes ❑No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? LI Yes ❑No Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement? 1,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 Z1`No ❑Don't know
<br /> 7. Is this to correct a violation? ... ❑Yes o
<br /> l �,
<br /> /,© 0 APPLICATION MUST BE SIGNED
<br /> �� (Continue on Back) -► -► -∎
<br /> 545-112(4/08)
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