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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to Web-App#
<br /> PROPERTY OWNER.INFORMATION° " ;:, ., ,,' �, ' �,��.�`,' 14 `< r-' -- `1 CUSTOMER TO PROVIDE
<br /> OWNER NAME
<br /> ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,/State,Zip) ' -537 Deed Restriction;CSM
<br /> 45/ C9�74;a D-€ tdd ' Variance(# )
<br /> HOME PHONE CELL PH, NNEE E-MAIL ADDRESS
<br /> • 3 3Qq ,� ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION:;: „ - CONTRACTOR;;INFORMATION " ::_,;, and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> %!1 S710 cScroei '1 d So--p►_L - ❑ Site Plan including location
<br /> AGENT``AD RESS CONTRACTOR ADDRESS of well/septic
<br /> o'.�J mist Qtr
<br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks
<br /> PHONE PHONE ❑ Site Plan approval from
<br /> c 2--OPS 6 c 75-- l(?f applicable township:
<br /> E-MAIL ADDRESS E-MAIL ADDRESS
<br /> ❑ Floor plans to scale
<br /> PROPERTY/LOCATION INFORMATION (http:7/accessdane.co.ciane.wi.usa
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property
<br /> ❑ N V BER (3,3F 07c8 043 (-217 0 A 1 f 3 Z frontage drawn to scale.
<br /> TOWNSHIP: SECTI N:
<br /> /91(dd(e -ter— _ 1/4.. .30 1/41/4: s6,..._ ❑ Driveway permits
<br /> ADDRESS (state,county,town)
<br /> CSM: -0 OT � l SUBDIVISION L BLOCK/LOT ❑ Sanitary permits
<br /> (public,private)
<br /> PROPOSED PROJECT INFORMATION ,,,' T A
<br /> PROJECT DESCRIPTION: � ,, .1. 3,'
<br /> T P l 7/''e/(/-5 77'T g `� 2 er /� ° 1,4®a�-e ,'
<br /> ' ,.,,,L;❑This project is a new building or structure. �e z� 9 ",- '; :
<br /> .�:iii r ,tea r„
<br /> his project is an addition/alteration to an existing building or structure. ' 1,-_-.-:.:'q_ '
<br /> SANITA Y SERVICE: �, �
<br /> PERMIT NUMBER: �1��� ����`�a i���K�� ;
<br /> ❑SEPTIC i, k :.
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement)
<br /> AREA TO NEAREST SQUARE FOOT: F
<br /> z
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) a ,. ';
<br /> BASEMENT: 1STFLOO 9 7 ! �
<br /> 7 ,, TOTAL SQUARE FOOTAGE: j vat=, k1, , --=`:a
<br /> v - � 4r it �ice).,:: 2`
<br /> 2ND FLOOR: 3RD FLOOR: //�� =
<br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ D ay� 7 9 . P.
<br /> Please round to nearest dollar
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes A o LI Don't know
<br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes re o ❑Don't know
<br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes ViNo
<br /> 4. Has there been a zoning permit issued for this property in the past 5 years? in 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 /> 7 Z-
<br /> APPLICATION MUST BE SIGNED
<br /> 545-112(4/08)
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