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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#, <br /> PROPERTY.OWNER:.INFORMATION° _ �,r;: i r <br /> OWNER NAME ` ` �� � ' CUSTOMER TO PROVIDE <br /> t?5 -5z4� o ❑ Zoning Status;CUP; <br /> OWN RADDRESS (Number,Street,TCiity,State,Zip) 1 Deed Restriction;CSM <br /> PHONE )er CELL PHONE, , E-MAIL on '. S3 /4 Varia ce(# <br /> HOME Ye.) Ly 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 /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION :;(http://accessdane.co.dane.wi.usn Li Elevation o <br /> of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: ❑ Driveway <br /> • , . .1/41/4: permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: T <br /> LI This project is a new building or structure. a �< <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: �g � <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: ` <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) A-z <br /> BASEMENT <br /> 1ST FLOOR: <br /> 4,, TOTAL SQUARE FOOTAGE: <br /> t.7, <br /> 2ND FLOOR: 3RD FLOOR: `= ' <br /> ESTIMATED CONSTRUCTION COST:( ♦ —► —1 —► <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 liii'No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes LENS <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if no ) <br /> 6. Is a location survey required? (see reverse) ❑Yes ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes L✓J No <br /> AA UST BE ED <br /> (Continue PPLIC on TION BacMk) —►S.SIGN► + <br /> 545.112(4/08) <br />