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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#. <br /> PROPERTY.OWNER..INFORMATION ti,,;= ,`_ gh w 40:s;:: .,-x._. f :R <br /> CUSTOMER TO PROVIDE <br /> OWNER NAM / �/ <br /> A�L1 ��� �.ti- �t -//17.� ❑ Zoning Status;CUP; <br /> OWNERber, g <br /> DRESS (N�m ,Street,City,State),,Zip) <br /> g/ Q J L, ..,"-Deed Restriction;CSM <br /> �i°'✓" �ti /'d_/i f ✓� Variance(# ) <br /> HOME PHONE �7 CELL PONE E-MAIL ADDRESS <br /> �g 5� l 7 i∎iib <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION . ,_ ;- CONTRACTOR;]NFORMATION and includes dimensions <br /> AGENT NAME CONTRACT•R NAME <br /> " _Tit. ,,i : , _ie• ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADORES:/ of well/septic <br /> %�.2Z',/Z1,:dy ' <br /> (City,State,Zip) (City, Zi ) ❑ Setbacks <br /> I Z <br /> l _,_—‘—', -3, -/( <br /> PHONE PHONE ❑ Site Plan approval from <br /> ��l Cam/ '9 2 7 applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 4.,;1/5COsl7/a,Cki, . 3 _`` L H plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danctuLus/): " ❑ Elevatif <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL frontage drawn to scale. ' <br /> NUMBER <br /> TOWNSHIP: SECTION: ❑ Driveway 1/. 1/1/. y permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION, <br /> PROJECT9FSCRIPTION:,, ' &{,dp <br /> 1::1 T is project is a new building or structure. s <br /> FR his project is an addition/al ation to an existing building or structure. L: r F <br /> SANITARY SERVICE: ' e o "1 4 <br /> PERMIT NUMBER: —" -I <br /> ❑SEWER SEPTIC ''' � w - , <br /> s .q � ST <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) k f ' ? I \ f <br /> .iat <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) , li i#�� � <br /> BASEMENT 1ST FLOOR: :; ®O , ® ,4 <br /> 4, TOTAL SQUARE FOOTAGE: 4, :, IJ a'i as <br /> 2ND FLOOR: 3RD FLOOR: // <br /> VI- l - <br /> ''1' <br /> ESTIMATED CONSTRUCTION � : <br /> V <br /> Please round to nearest dollar ♦ ♦ ♦ ♦ ♦ -i 2. Q � � ;v„ t <br /> / <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L11'N ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IN ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? CI 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(pgtition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes �❑Noo, CI Don't know <br /> 7. Is this to correct a violation? ❑Yes W-o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► -+. —► <br />