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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> i Gti\c- 16 W t-\\S LI Zoning Status;CUP; <br /> ER ADDRESS umber,Street,City,Stat Zi t,,/� (� Deed Restriction;CSM <br /> S 2'0 4 Qr N\Z41-- � �Y ,61\ a v-\ Uj\ --.)3—k `i Variance(# ) <br /> HOME PHONE CELL PHONE E- AIL ADDRESS <br /> k el i. � u , ,•v. Li Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> GENT NAME ` CONTRACTOR NAME <br /> 0.�i� W\ t tr\�� e, � �\ 9 (_`\S ❑ Site Plan including location <br /> AGENTADDRE CONTRACTOA ADDRESS of well/septic <br /> S 2 v �' L.r 1__I .ZQ Lin-2.a_ ii) . <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> %. W \ 51"1 \i YV1&' So v\ UU■ S 31 \ i <br /> PHONE PHONE ❑ Site Plan approval from <br /> o Q 1 A1/4-kL.k L-1` . (00 `-1LN L applicable township. <br /> EMAIL IL ADDRESS -MAIL ADDRESS <br /> bW E' C N,, ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLusn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> PARC p q frontage drawn to scale. <br /> NUMBEL tER V\yfc$\�-ts -q�s0-� �, • ! 1� g <br /> TOW SHIP: SECTION: <br /> v.(LX- � 1/4: 1/4%.. ❑ Driveway permits <br /> ADDRESS: ,(fin (state,county,town) <br /> SZ, V, \N\JL V_� 1 V l(k�1 i 53,— �■ s�"1 ■cZ ❑ Sanitary permits <br /> CSM: LOT / SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATIO A� <br /> PROJECT DESCRIPTION: 0 :','„,In- ,-,gE , ',°-yam � <br /> . LI This project is a new building or structure. :21;,.-„z--,-.. ' <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: . ^ Po , °° <br /> SEWER ❑SEPTIC ' '-� ,` <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � � 31,;,,,'!", <br /> AREA TO NEAREST SQUARE FOOT: 4 a- ' r <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) -' '� a� d <br /> as m <br /> BASEMENT: 1ST FLOOR: 4 4, TOTAL SQUARE FOOTAGE: 4, _., - sl ` � <br /> 1 <br /> 2ND FLOOR: 3RD FLOOR: a A <br /> ' # � 4 <br /> ISO !: e�.:-ii: <br /> ESTIMATED CONSTRUCTION COST: , oq s � e :Pe e a�a <br /> (Please round to nearest dollar) -■ -' ( Q (3 fw ' ,v ,Q <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? IYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? In Yes ®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 IRE 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) Li Yes ®No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1.X1No <br /> APPLICATION MUST BE SIGNED <br /> 545-112 la/osl (Continue on Back) -i -0. -∎ <br />