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11 .1.--1 5 <br /> t(z, 4 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App 3/ <br /> • <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME . <br /> Y e-Q.-t'c l d oV 1 f S Lc._c_ 0 zoning status;CUP; <br /> OWNER s (Number,:. - t°. - t Deed Restriction;CSM <br /> I 01 6 r Lo 131 1 ' lit Lo Gat 5. 1i Variance(# ) <br /> HOW CELL PHONE E-MAIL AODRESS <br /> 4� 3l cy� 0 Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5.0J.` AtIb ye <br /> - AS Plan including location <br /> AGENT CONTRACTOR ADDRESS of well/septic <br /> (City.seta.MP) (Clty,Stata.AP) ❑ Setbacks <br /> PHONE PHONE ' ❑ Site Plan approval from <br /> applicable township: <br /> E-MAILADDRESS E-MAJLADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:/.'aceessdane.co.dane.wi.us/) <br /> 0 Elevation of property <br /> PARENT PARCEL NUMBER: CURRENTZONINe- ACREAGE: frontage drawn scale. <br /> 0 PARCEL ", E 1] �j to <br /> C)TOWNSHIP: \ _ ` - SECTION: ❑ Driveway permits <br /> Th 1d�1� Gr1 '�4. '�'�4. (state,county,town) <br /> ADDRESS: / /z <br /> T Ir7 2 C l 11.4- 0-124 L ❑ Sanitary permits <br /> CSM: LOT SUDOMSjON BLOCK/LOT (public,prlvate) — <br /> PROPOSED PROJECT INFORMATION • <br /> PROJECT DESCRPON: S <br /> _ ..k., o r,Str,C -„ t • <br /> . l l s <br /> project is a new building or structure. • <br /> 0 This project is an addition/alteration to an existing building or structure. <br /> SANITARY S al — QFRMITNUMSER:_ <br /> -- _ <br /> ❑SEPTIC -- w * $ a a ee <br /> HEIGHT IN FEET 3 D i k • NUMBER OF STORIES: (Nd Including bas-Mont) <br /> 1 • <br /> AREA NEAREST SQUARE FOOT. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> -BASEMENT 1ST FLOOFrr,. <br /> ��_ j TOTAL SQUARE FOOTAGE: j <br /> `7 4fs” <br /> I <br /> 2ND FLOOR I 3RD FLOOR: t-f CI C <br /> ESTIMATED CONSTRUCTION COST. „� ♦ ♦ ♦ $ ( DO <br /> (Please round to nearest dollar) V' o I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes LiSNo .0 Don't know <br /> 2. Is there a wetland orfioodplain on or near the property? Cl Yes CNo 0 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? IJYes 0 No <br /> 5. Is this project associated-with a rezone/CUPNariance(petition/appeal# ) (i 've blank If none) <br /> 6. Is a location survey required? (see reverse) Yes 0/No ❑Don't know <br /> 7. Is this to correct a violation? 0 Yes t!a No <br /> APPLICATION MUST BE SIGNED <br /> (Continuo on Back) -P -* -+ <br /> 545-112(+Ina) - 5 g s 7 <br /> F.--id <br /> EY 3(-5 <br />