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I I.. <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App#, <br /> PROPERTY OWNER INFORM A TION ti; __; :7 � -0 441E r i.._ r,1, CUSTOMER TO PROVIDE <br /> OWNE1E <br /> W rr 12' / /5-0)•J <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> Z &/ , \ V� Variance Restriction;CSM <br /> �N�' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS / <br /> ZZ'� —.1-19'O r. Lb/(,SctJ@ C/ic .iw� e ,i, - I 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 /> • <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:llaccessdane.co.dane.wi.usl) .., ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL frontage drawn to scale. ' <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/: %-y: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: <br /> 28 447,204(4 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION; - <br /> f r � a �? <br /> x <br /> PROJECT DESCRIPTION: / � t'��(i.„1 t- s-40 ,�CL)/Al M /k)( �,(2)6 G j/ u'�d^� ��i"' { .3; <br /> ❑This project is a new building or structure. �; p� <br /> �S F�kr. p�aB�spa€���m "'�? Y <br /> ❑This project is an addition/alteration to an existing building or structure. -SANITARY SERVICE: PERMIT NUMBER: 2 Att i a 4, <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) : - ,i ';" <br /> -1 # <br /> AREA TO NEAREST SQUARE FOOT: ' -� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) :`� - '� <br /> BASEMENT: 1ST FLOOR: R 61 �"` <br /> ,I, TOTAL SQUARE FOOTAGE: l �'� . 1'r. <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST e e - g s`e <br /> (Please round to nearest dollar) "� ''''.1',. --1,--.1",t'47,-,. f ' - <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 /> (Continue on Back) —► —► —4 <br /> 545-112(4/08) <br />