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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> . <br /> OWNER NAME <br /> (Q"t .S ' 0�i1-2.-- ❑ Zoning Status;CUP; <br /> OWNERADDRE (NympeL street,City,state,ZIP) co u Deed Restriction; CSM <br /> 2'R Sq. e� Q Variance(# ) <br /> HOME PHONE 1 CELL PHONE I., E-MAIL ADDRESS <br /> I`` I i tZ f 669�!'O— 132_ be-f'Z_ 3 � co, % ❑ Site Plan drawn to scale <br /> AGENT INFORMATION p CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME �y CON RACTO{R�NA E <br /> pi. c hate L J t 12g O r'T Vt kid 1614 IN tt ❑ Site Plan including location <br /> A ENT ADDRESS ,,11 "��',/ CONTRACTOR ADDRESS Boy well/septic <br /> Same as I"p i z y OWK 3 I PN cfrr ' 'iot B y �© ❑ Setbacks <br /> (City,State,Zip) (City,State, <br /> PHONE 8rotoosviIle, ifc,)z".S'3f�h, <br /> PHONE LI Site Plan approval from <br /> 42o -193--2_<(14 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS // <br /> UO 1 &fr » • - atilt r_ ; 4;46; 1114loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL I frontage drawn to scale. <br /> NUMBER n 12104 II"Pi�"ic�q'� �—I {r�� <br /> TOWNIr�to I 0/\ SECTI N: <br /> 66 (�/// '/<: S '/a'/a: S Li Driveway permits <br /> ADDRESS: (state,county,town) <br /> za 3R P .)11 1k lI j/ 620,r ❑ Sanitary permits <br /> CSM: LOT l AUBDIVISION BLOC (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: p 1�y $ '' „ I <br /> . This project is a new building or structure. 4 <br /> t <br /> ❑This project is an addition/alteration to an existing building or structure. t '� <br /> SANITARY SERVICE: N +e <br /> PERMIT NUMBER: <br /> ❑SEWER )I SEPTIC a s <br /> HEIGHT IN FEET: / // / ` BER OF STORIES: (Not induding basement) ;% `':. "£ 4 <br /> � ) <br /> AREA TO NEAR SQUARE FOOT: 14 . <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: s m t` a ", ¢ a v t : <br /> MO t&Q ! 1QC) 4,, TOTAL SQUARE FOOTAGE: j + + + <br /> v ° ilia s' - � �-��„ <br /> 2ND FLOOR: 3RD F OR: I Q77 , <br /> A1x1A <br /> ESTIMATED CONSTRUCTION COST: $ ® a <br /> (Please round to nearest dollar) ♦ ♦ ♦ . ' ♦ ♦ $ i 2 f * a a 7. r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 1 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes A No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? NtYes ❑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 XNo LI Don't know <br /> 7. Is this to correct a violation? ❑Yes A No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ –► - <br />