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ZONING PERMIT APPLICATION wwcountyofdane.com SUPPLEMENT-to Web�App# <br /> w. <br /> PROPERTY OWNER`.:INFORMATION _ '.,� ;y ,S,�, t i- . <br /> OWNER NA <br /> � ��� --��~� ° �'= �` CUSTOMER TO PROVIDE <br /> -e - X r ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed Restriction;CSM <br /> A - `/ Variance(# ) <br /> HOME PHI NE • E-MAIL ADDRESS <br /> 7S--Z- ❑ Site Plan drawn to scale <br /> AGENT INFORMATION ;'i CONTRACTOR INFORMATION ,:? and includes dimensions <br /> AGENT NAME CONT'• TOR NAME <br /> i o _ _ i - dt, ,_ ❑ Site Plan including location <br /> • CON RAC OR ADDRESS of well/septic <br /> _• <br /> EMINEME <br /> (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE 0 ❑ Site Plan approval from <br /> t applicable township: <br /> E •IL•DDRESS E-MAIL ADDRESS <br /> (0 Li plans to scale <br /> s ._: <br /> PROPERTY/LOCATION INFORMATION ':(httpJ/accessdane.co.dane.wi.usn ❑ eva <br /> Elevation <br /> PARENT CURRENT ZONING: on of property <br /> P rtY <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER MEM= — <br /> TOWNSHIP: SECTION: <br /> Q.5' 1/. i — 1/41/4. _ ❑ Driveway permits <br /> #- — — (state,county,town) <br /> i ❑ Sanitary permits <br /> LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION. ' :' <br /> PROJECT DESCRIPTION: '- '4 , ., <br /> / to - �- .., ,.c p <br /> - <br /> f r A. L - _ - +`° L aLis. ((C1 _, sb". ` a := 'ra aka <br /> • This project is a new building or structure. Kid-, t� �: ,, <br /> ❑This project is an addition/alteration to an existing building or structure. ' - , � <br /> SANITARY SERVICE: PERMIT NUMBER: —44, ear;Y. - = <br /> ❑SEWER lie SEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) :? ,„'Y <br /> AREA TO NEAREST SQUARE FOOT: w ; -. <br /> (Outside dimensions including unfinished area,attach-d garages and above grade decks or porches) gP , <br /> BASEMENT: 1ST FLOOR: �� �,Q® � ::� Fh <br /> 4, <br /> (� TOTAL SQUARE FOOTAGE: 1 ,�i , <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: 11114111 c i tin € <br /> (Please ) --► --I. -► -� --► -► $ - `_- e e 1 �a 91P <br /> Please round to nearest dollar) IIIM r 7. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ❑No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Li Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Li 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(petition/appeal# ) (leave blank 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 ❑No <br /> 2 <br /> tC) APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i -► <br /> 545-112(aros) &-4° <br />