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ZONING PERMIT APPLICATION www.countyofdane.com ,SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION _ '.,-,V�.d, <br /> ._ ' 43 ;. ,-.,-. :` �, <-- `..=° CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> Gp I L 5 re6 °S ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> -2-Z 13 Scu\l-lvl'fLAJ PI) Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 0'35 -5Z` <br /> l!d Site Plan drawn to scale <br /> AGENT INFORMATION , , CONTRACTOR:INFORMATION r ;:•-%. and includes dimensions <br /> AGENT NAME c M*€l-E CONTRACTOR NAME <br /> Ez) Sco )k, 2P-S 1 Et4ite Plan including location <br /> AGENT ADDRESS CONTRACOR ADDRESS T <br /> r D i )& /c ��of well/septic• <br /> (City,State,Zip) (City,State,Zip) tJ Setbacks <br /> 09_12,00,1J i u 5357 5 <br /> PHONE /�p PHONE ❑ Site Plan approval from <br /> �3 S - �S q1 o g applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS r�.� <br /> Ud'FIOOr plans to scale <br /> PROPERTY/LOCATION;INFORMATION (http://accessdane.co.dane.whusa <br /> Elevation of <br /> PARENT PARCEL NUMBER:I p 1 CURRENT ZONING: ACREAGE: property <br /> ❑ NUMBER 0A 1 O i 9'T Oc4.©_.1 frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 0).) >J <br /> 1A: 1/1/: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> -Z-Z-1 3 SotA N vw'') « ❑ Sanitary permits <br /> cSM: No 1 LOT / SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION - A <br /> PROJECT DESCRIPTION: <br /> ❑This project is a new building or structure. . ,, - , - ,zf <br /> -' This project is an addition/alteration to an existing building or structure. ',.S- <br /> SANITARY SERVICE: PERMIT NUMBER: itr44 °' ,: <br /> 0 SEWER SEPTIC - � s <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � t-#� <br /> AREA TO NEAREST SQUARE FOOT: F . , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' - , . '` r-----BASEMENT 1ST FLOOR: ®� �g ® F� <br /> 6 1 TOTAL SQUARE FOOTAGE: 4, - ,� tde a A `� , <br /> . 4� tr <br /> 2ND FLOOR: 3RD FLOOR: ;tie €�� � <br /> de '-',15_,,i: <br /> ESTIMATED CONSTRUCTION COST: .4. _0. -► -► -► -i a g a ® m �s <br /> �Please round to nearest dollar) € �� , s � -, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 'A-No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 4 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 V Don't know <br /> 7. Is this to correct a violation? Li Yes ,0 No <br /> APPLICATION MUST BE SIGNED <br /> 545112(4/09) <br /> (Continue on Back) —► —► —► <br />