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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT;tO.Web-App#. <br /> PROPERTY OWNER INFORMAT,,ION„;. - „z=x_, s�?°' ,41.,;„0 ,_;, ,. W,.,, 0r CUSTOMER TO PROVIDE <br /> OWNER NAME •—Mal L ` P ❑ Zoning Status;CUP; <br /> O��"/'R ADDR SS umber,Street,City,State,Zip <br /> /nil O a° KY/ (iC.) Sha //V 1 S j Deed Re(triction;CSM <br /> _ / ) <br /> Variance # <br /> H PHONE CELL PHONE E-MAILADDRESS � <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION ..' ,_ . ;; CONTRACTOR;:INFORMATION and includes dimensions <br /> AGENT NAME , CONTRACTOR NAKE <br /> It • A % a /0,, 4.1 I, !C Al! ❑ Site Plan including location <br /> AGG�TADDRESS i RA TOR ADDRESS of well/septic <br /> I I !l . a �L♦ / 1 <br /> (C'ty,State,Zip) (Ci,,State,Zip) ❑ Setbacks <br /> lb <br /> PH -ONE ❑ Site Plan approval from <br /> 1-c7(1(0 (oO) 7 5 -'f r j t O7 applicable township: <br /> E D-4 S • E- AIL ADORESS <br /> ' ' , j 1 4 ' 0 € ' oho LI Floor plans to scale <br /> PROPERTY/LOCATION:INFORMATION;?(httpalaccessdane:codanewrf uslj:: ' . ❑ Elevation of property <br /> PARENT P CEL NUMBER: CURRENT ZONING: ACREAGE: P P rtY <br /> ❑ PARCEL /�1,����,_��5� - frontage drawn to scale. <br /> NUMBER <br /> TOWNSHI SECTIO l A-)6 ❑ Driveway permits <br /> AD//DRESS: I (state,county,town) <br /> /ADDRESS: a ! i ) ❑ Sanitary permits <br /> CSM: ` LOT SUBDIVISION BLOCK/LT <br /> II '. C�9 0 (public,private) <br /> PROPOSED PROJECT INFORMATION, t 'if' ,.� <br /> PROJECT DESCRIPTION: a ;. ?'�r <br /> ❑This project is a new building or structure. Vii. t <br /> 0 This project is an addition/alteration to an existing building or structure. - ° . <br /> 1 r � r � , y <br /> SANITARY SERVICE PERMIT NUMBER: . 4ir <br /> ❑SEWER ❑SEPTIC Me <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> s <br /> Uapi of is 1 e1 K 6 1 <br /> ci ` y <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) r st i = ±., <br /> BASEMENT 1ST FLOOR: ®; � o�t���e ® �.. <br /> 4„ TOTAL SQUARE FOOTAGE: e ;" <br /> 2 <br /> x to `�,R, .x <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ;s ge e t�� - <br /> (Please round to nearest dollar) , , ,, n :;: <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► --0- —► <br />