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ZONING PERMIT APPLICATION .countyofdane.com SUPPLEMENT to Web-App#: <br /> PROPERTY OWNER.:INFORMATION . _ _:, 0,d? 07.1 : ,.-._ !., ?_e , i -OWNER NAME CUSTOMER TO PROVIDE <br /> -■4 Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> it eed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADD"ESS / <br /> Il=■ Site Plan drawn to scale / / ,>0 <br /> AGENT INFORMATION .•; CONTRACTOR:INFORMATION', ° -"-: .nd includes dimensions <br /> AGENT NAME CONTRACT 0R NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACT 0R ADDRESS f well/septic / /4- <br /> (City,state,Zip) (City,State,Z.) Setbacks 56//0/...5-©/5 0 <br /> PHONE PHONE ite Plan approval from <br /> / <br /> (� applicable township: <br /> E-MAIL ADDRESS E-MAIL ADD^ESS ( „ / <br /> ►l Floor plans to scale JJ1ll/ <br /> PROPERTY/LOCATION INFORMATION (http:llaccessdane.co.dane.whusa Elevation of e <br /> PARENT PARCEL NUMBER: CURRENT Z a NING: ACREAGE: property P dy <br /> 0 PARCEL frontage drawn to scale./ <br /> NUMBER <br /> TOWNSHIP: SECTION: • <br /> • <br /> 14 /� <br /> : 1/1/4: ££ Driveway permits <br /> (state,county o n <br /> ADDRESS: <br /> A 41 <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, ' <br /> PROPOSED PROJECT INFORMATION. P TA: t� � <br /> PROJECT DESCRIPTION: '' It', <br /> ❑This project is a new building or structure. i ® 11,6. , • <br /> ❑This project is an addition/alteration to an existing b ilding or structure. 5:::47::_ l/ <br /> SANITARY SERVICE: PERMIT NUM=ER: -; I r -EiK � /\ <br /> ❑SEWER ❑SEPTIC �Xi -'t- '`W` 3. <br /> A» i <br /> HEIGHT IN FEET NUMBER OF ORIES: (Not including basement) -, <br /> AREA TO NEAREST SQUARE •00T 1 <br /> (Outside dimensions including unfinished area,attached gara•e. and above grade decks or porches) l'-' ` <br /> BASEMENT: 1ST FLOOR: P � � u , ,'..: A_ /9) <br /> 4, TOTAL SQUARE FOOTAGE: 4 -4/ t1• E J : .g r 1 <br /> 2ND FLOOR: 3RD FLOOR: � / -re <br /> "':'• -1 01 } 4 d <br /> ESTIMATED CONSTRUCTION COST $ /g0/70 e;� <br /> � ® se #"'∎ "- "r --∎ -� � � A(Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 fee from a pond or lake? ❑Yes %No LI 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 a d are they in agreement'? ❑Yes No ,t� / �1 <br /> 4. Has there been a zoning permit issued for this prope in the past 5 years? Yes No 2,?)1 C C !� L` <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan 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 tNo /p <br /> ,. 2 S�Z�co <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />