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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 /> �11� k / cj 1i VtiCi <br /> `\yx, oning Status; CUP; <br /> OWNER ADDRESS (Nurrper,Street,City,State,Z M Deed Restriction; CSM <br /> V lcT,�-Z�v,bi��L�e�t �� O!►4 �Cri'1CiN, , Variance(# ) <br /> HPHONE CELL PHONE E-MAIL ADDRESS <br /> ,G.-6 1/119 3 3 -3 560 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions' <br /> AGENT NAME CONTRACTOR NAME <br /> c9 Pi >✓ 0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic No <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks 140 <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL <br /> ❑ Floor plans to scale 1JIU <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Li Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL / ,, ( ) frontage drawn to scale. <br /> TOWNSHIP: <br /> NUMBER SECTION: h+4- `�/ /G 3 7 <br /> (0X��' `� 33 '/: %1/: Hi,Driveway permits <br /> ADDRESS: (state, county,town) <br /> / <br /> 8758' i(oft z En Ai uec-L I Q f1 rye J-c mcc h I G IVY 5-3...<6.0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION TO-sit <br /> PROJECT DESCRIPTION: <br /> Sk` e 6 p <br /> This project is a new building or structure. } v T ., <br /> e1 = <br /> ❑This project is an addition/alteration to an existing building or structure. 16.k;.!;,,,. ..:! -:-': :' ; , ,� <br /> SANITARY SERVICE: PERMIT NUMBER: tr k z �„' <br /> ---sz.n ,,- tic,�� <br /> SEWER SEPTIC ne extsti g <br /> HEIGHT IN FEET i NUMBER OF STORIES: (Not including basement) ' �',' <br /> S Z °* o e an s a r merit) <br /> AREA TO NEAREST SQUARE FOOT: . .63 3, ° ;.r g ' <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) ,'° ' - <br /> 6.51 J 3 Six ` :•BASEMENT: 1ST FLOOR: D t ° ° y <br /> 3Js " 25$ ,j, TOTAL SQUARE FOOTAGE: ,, ",�'j'O° r ° <br /> 2ND FLOOR: y 3RD FLOOR: JJ •' �� I ` <br /> ESTIMATED CONSTRUCTION COST: -s t <br /> 6 0 °°i E <br /> (Please round to nearest dollar) ♦ -i '♦ ♦ ♦ "� 00 -.p P1 =.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El No 0 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ZiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes Li 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# ) (le ve blank if none) <br /> 6. Is a location survey required? (see reverse) ,JYes No ❑Don't know <br /> 7. Is this to correct a violation? DYes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► <br />