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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 /> 0‘4/170 El Zoning Statu • UP; <br /> 6WNER ADDRESS ( umber,Street,City,State,Zip) <br /> Deed Res ction•CSM <br /> if 'S /G/&, V �l i i,'7 2,fib' 6..4 HOME PHONE ELL PHON E-MAILADDRESS 1ariap (# <br /> ite Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> \-1 if M X.0 ea 4 A A/0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (/s—ss NU, y s <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> PHONE PHONE ite Plan approval from <br /> g0 e 7S, - y 5—,2,‘. applicable township. <br /> E-MAILADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us!) <br /> PARENT PARCEL NUMBER: CURRENT ZONIN : ACB AGE: E evation of property <br /> ❑ PARCEL , (R ? / - �(/Q^ _� ( L�; `� f outage drawn to scale. <br /> NUMBER 1 / /jC' 111 '7 �! <br /> TOWNSHIP: a SE TION: <br /> �/P.0_C.0 /. A--W- ' - 1/a: 10 1/a1/a: 1\si riveway permits <br /> ADDRESS: state,county,town) <br /> V 7‘ 9 /16y y �( //Q/2 Vie' w 1' " s 7 7 - Sanitary permits <br /> CSM: L T SUBDIVISION BLOCK/LOT (public,private) <br /> ' i 7."S S <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION: / <br /> • <br /> "�! \Kf/ C. ( - Q ('C II ,.fling District <br /> 21 This project is a new building or structure. ' Permitted Use? <br /> Cl This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: .,, , 01 Rural '.= - <br /> 0+t(--. <br /> 0 SEWER ll/SEPTIC 9 (rte t-xtsting) <br /> HEIGHT IN FEET: NUMBER OF STORIES:R (Not including basement) <br /> ❑ lhfe#Ian Blain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shor nd (attach o-nt) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ "CC1SItMG•' a.; I <br /> 9 2 s`" - ,, TOTAL SQUARE FOOTAGE: 4 (slope +tstutbant , <br /> 2ND FLOOR: fills •,access <br /> 3RD FLOOR: ) ° <br /> ❑ Review tiO Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and ailable options. <br /> (Please round to nearest dollar) $(';2....... L/1 C 4 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ($l No Cl Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑)ies No 1.3 Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? 19rYes ❑ <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan if one) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► ■ -+ <br />