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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to Web-App#, <br /> PROPERTY-OWNER::INFORMATION ,.,; _ ,' -4: a,TM, �,-;°, <,,-11: <br /> ' CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 15 U54 / I ❑ Zoning Status;CUP; <br /> OWNER ADDRESS Numbber,/Street, ity,State,Zip), <br /> /656S /�udso/7 /(1 /I/ 1432:-.5:5-S-6 Deed Restriction;CSM <br /> U�OhP4�/i t.° Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS r <br /> 9,5-.0107 c;i 3 C-9Z ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR 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-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Flo. plans to scale <br /> PROPERTY/LOCATION;INFORMATION::(http://accessdane.co.dane.wi.usn" - �:tionof property PARENT PARCEL UMBER: CURRENT ZONING: ACREAGE: P P y <br /> ❑ NUM ER 054/6�1b 46/ -.F6G�.. `,-. /6,e2 % tage drawn to scale. <br /> TOWN HIP: SECTION: Driveway�{ oGyIQ 41/ °lam IA: 1/4%: y permits <br /> ADDRESS: / (state,county,town) <br /> /6363 -77ud56/i /ed. 111aro«Q/I/� �� S=3S�o <br /> / / ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION,,"` a <br /> PROJECT DES RIPTIO : <br /> V <br /> aThis project is a new buildi • or structure. 4 ' " - <br /> ❑This project is an addition/alteration to an existing building or structure. N - --. V, , s <br /> SANITARY SERVICE: PERMIT NUMBER: it ° trt. <br /> n� k C3 SEWER ❑SEPTIC ' ? •} <br /> > - <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) " " t -' `' <br /> nr � °.t •a <br /> vS _ �ec Asa�A t� <br /> AREA TO NEAREST SQUARE FOOT: b <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' ' -re ` 4 " <br /> BASEMENT 1ST FLOOR: e ®�p�IS r <br /> 1 60 / 1— 0 4, TOTAL SQUARE FOOTAGE: ,1 4 gic ,`, I <br /> 2ND FLOOR: 3RD FLOOR: 7 1 TO 3 � <br /> , ears -`emu€ <br /> ESTIMATED CONSTRUCTION COST: -+ -► -► '- .- -* app pv ' a i g ke _ l <br /> (Please round to nearest dollar) ; , : -, <br /> 1: <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? f'es ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? 'Wes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? .®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 I No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes )0 No <br /> i <br /> S`(7i APPLICATION MUST BE SIGNED <br /> 545-112(aloe) o/r�8. Da (Continue on Back) -► -► -I► <br /> / .7 <br />