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<br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App #
<br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE
<br /> 0 f NAME ,(�
<br /> I h �"'�a/ d 12 a e (G, /"sac K7 e ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM
<br /> 776 S(9 If t i (e C14 Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL
<br /> EADDRE S ,bog I/6-S t6 6°F-a-o.-Q66S trrr4ckrec it , ,ee
<br /> c ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRAC OR NAME
<br /> ❑ Site Plan including location
<br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> applicable township.
<br /> E-MAILADDRESS E-MAIL ADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property
<br /> PARENT PARCEL NUMBER: CURRENT.ONI G: ACREAGE: P P y
<br /> ❑ PARCEL o3%/v�08 _I�i....105/....0 esi d o 4I f frontage drawn to scale.
<br /> NUMBER l�
<br /> TOWNSHIP: SECTION:
<br /> 07 P 1A: lV 1/41/4: �_" ❑ Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> 17 6J SO Is--rCe C r , Vevoo a tivI
<br /> CSM.O LOT I SUBDIVISIdN BLOCK/LOT ❑ Sanitary permits
<br /> !1 $au k POig4 F 1 (public,private)
<br /> PROPOSED PROJECT INFORMATION
<br /> PROJ CT DESCRIPTION: :' . , 4, '1
<br /> CI X aq( cohcvCl Pad L €14 I• Ic1uHG 12.-(rh A, �oufe `CJ o I ® t n �
<br /> ❑This project is a new building or structure. l
<br /> 0.This project is an addition/alteration to an existing building or structure. ''=,F ,' ,Ne.� ^ � n - k r
<br /> SANITARY SERVICE: PERMIT NUjvIBER: '4,,,,,,r'" ,■❑SEWER 0 SEPTIC /v A- Tt r - s�I •� ".1:4 �f '>
<br /> �.
<br /> HEIGHT IN FEET: NUMBER Or STORIES: (Not including basement) " -'1',:4;',1.7.1,,:,.�
<br /> R. , 1 '
<br /> AREA TO NEAREST SQUAREE FOOT: l , "" z�
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r x z':' t ?4.0%'4:11;:_i_","e
<br /> BASEMENT: 1ST FLOOR: ) ,'„/19014,..r 11�`+•[ ,• p, , ,
<br /> j TOTAL SQUARE FOOTAGE: 4, wi•IS,U • • x
<br /> 2ND FLOOR: 3RD FLOOR: ^ /�/ f Illn•Ian S' t'
<br /> 0 • rve 44:
<br /> ESTIMATED CONSTRUCTION COST: . o t�
<br /> (Please round to nearest dollar) "'∎ —∎ —∎ -4. $ d'3 s • a I . d O . s y
<br /> i
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes F "No ❑Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®1Jo ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? 26es ❑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 ,-3✓o Cl Don't know
<br /> 7. Is this to correct a violation? ❑Yes 'No
<br /> APPLICATION MUST BE SIGNED
<br /> (Continue on Back) —► ■ —►
<br /> 545-112(4/08)
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