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ZONING PERMIT APPLICATION www.countyofdane.com 4SUPPLEMENY to.Web-App#: <br /> PROPERTY OWNER:INFORMATION„1 ,, i, ;„ tt,W4"-3 a,,41 1 ;.* '. CUSTOMER TO PROVIDE <br /> OW .9R NAME <br /> / 1t.(/E 6 F_ Se:Attfis p Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> a5/ 7 1//i 3l`, /w4/ 1'$ 13 7/3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> / -75 S^73 23''4( a Site Plan drawn to scale <br /> AGENT.INFORMATION ,>-. . ; CONTRACTOR:INFORMATION 1 :nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ite 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 /> 11 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION:INFORMATION (http:iiaccessdane.co.dane.wi.usn .. <br /> PARENT PARCEL NUMBER: C ENTZON G: ACREAGE: ► levation of property <br /> ❑ NUMBER e-76 3H I-' 0-15-1 y-'3 ..3--) frontage drawn to scale. <br /> TOWNSHIP: SEQTIO <br /> Pnd ;..S p " N: <br /> t) '/4: N E Y44Y4:w W a ermits <br /> ADDRESS: 3'gtia. <br /> t nry,town) <br /> . 0 6)4 vf-c r- <br /> S. -la •ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (pUb�private) <br /> PROPOSED PROJECT INFORMATION; .. , . %`"`-sTA RE IEW <br /> PROJECT DESCRIPTION: - -c,-r' M <br /> This project is a new building .r structure. `, 'Q` ` v . <br /> ❑This project is an addition/alteration to an existing building or structure. i -f � 4 <br /> SANITARY SERVICE: PERMIT NUMBER: t' EV-F _ °a a �� Cv <br /> EWER (N r - <br /> HEIGHT IN FEET NUMBER OF ST R S: Not including basement) 7L a > <br /> l' ) ®6 QgaaT "` 44"Tr <br /> • I.. <br /> AREA TO NEAREST SQUARE FOOT: F P � =r� ' <br /> (Outside dimensions including unfinished area.attached garages and above grade decks or porches) 4' ��3 ` `�''' <br /> BASEMENT: 1ST FLOOR: - e e= ®� e , <br /> 3) 4, TOTAL SQUARE FOOTAGE: 4, ' 1 am- 1r �, <br /> 2ND FLOOR: 3RD FLOOR: <br /> 4.413 4-#417A agi4r <br /> ESTIMATED CONSTRUCTION COST: <br /> - emd� <br /> (Please round to nearest dollar) '♦ ♦ -+ "� -+ "i ,�- . -� - <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ltd Y s ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? UdYes 056 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ap <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I. 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) ,-.C-�Yes ❑No ❑Don't know <br /> L <br /> 7. Is this to correct a violation? Yes ❑No <br /> ALIAUST BE SIGNED <br /> (Continue PP C on TION BacMk) —► —► —0 <br /> 545-112(4/08) <br />