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ZONING PERMIT APPLICATION www.countyofdane.com SUppLEMENT_to Web-App# <br /> PROPERTY OWNER INFORMATION ti=,_. .' ,� ?..'; ,: ;-t <, ?; ";,, CUSTOMER TO PROVIDE <br /> OWNER IE So.c <br /> / /cei�/ j ..`- 'es A P...-e"/OWNER ADDRESS Number Street c State Zoning Status;CUP; <br /> ( City, Zip) Deed Restriction;CSM <br /> /5-76 nt//U$7 Crass P i//S LOS 5-35- Variance(# - ) <br /> HOME PHONE CELL PHONE E-MAIL ADD ES <br /> r <br /> �' - ' , a, 1 / i ❑ Site Plan drawn to scale ,` <br /> AGENT INFORMATION.-:_, :f CONTRACTOR INFORMATION',' ;,_ , and includes dimensions <br /> AGENT NAME CONTRACTOR NAME "`...._._.0 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) <br /> - 2i Setbacks <br /> PHONE PHONE . g Site Plan approval from <br /> applicable township <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale -; <br /> PROPERTY/LOCATION;INFORMATION (http://accessdane.co:dane.wi.usn <br /> PARENT = CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL • 4/_ / frontage drawn to scale. <br /> NUMBER A • , 41 t la <br /> TOWNSHIP: _ a SECTION: <br /> gait/ c,r' '/ e 9.9 + : Sur ,%1/: 4)W 12(Driveway permits <br /> ADDRESS: (State,county,tOln <br /> CSM: LOT SUBDIVISION BLOCK/LOT "� Sanitary permits <br /> (public,prtvat __. <br /> PROPOSED PROJECT INFORMATION ` �° <br /> PROJECT D RIPTION: y� + , <br /> L e. ' 4 e L. I - �' °, ? / ��/) <br /> ,This project is a new building or structure. �t � <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: . ( <br /> ❑SEWER SEPTIC ''( , 'k' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) t <br /> c / a - ' a $ A -AREA TO NEAREST SQUARE FOOT. -`� �' 1 2 : - 4 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porch -,--- a : ›z rr C <br /> BASEMENT: 1ST FLOOR: y , °1, °1 ® ! <br /> 4, TOTAL SQUARE FOOTAGE: a .L :, -� pt <br /> � .��_ 4 r <br /> 2ND FLOOR: �. <br /> 3RD FLOOR: <br /> b <br /> ESTIMATED CONSTRUCTION COST: i`� <br /> > -► -► -► -► -► -' C)0 U v <br /> (Please round to nearest dollar a i U , 1 � . <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? (Wes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 5d'Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? alYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes allo <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 /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) -► -■ -■ <br />