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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com 1jUPPLEENTtO1eAPP#: <br /> PI <br /> ROPERTY OWNER;:INFORMATION`..i.s, _ . Y=_: ?.'� �,,��:; ,_..._. - <br /> OWNEIIN �C L ~` CUSTOMER TO PROVIDE <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ^ ❑ Zoning Stat , P; <br /> 4910 ANA Cc. ) ,M J J,r 4. 0.);(537)) n. ' '� �� C r Deed tjas riction;CSM <br /> HOME PHONE �� - CELL PHONE E-MAIL ADDRESS <br /> �Ite <br /> (o) o - ' . 3/5o C k a L l e t c e- `1✓�1 S 4,�rn Plan drawn to scale <br /> AGENT INFORMATION .. CONTRACTOR;INFORMATION' nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME A <br /> AGENT ADDRESS nel'lM !1 es— See. A ,,,,re_ Site Plan including location <br /> CONTRACTOR ADDRESS (of well/septic <br /> (City,State,Zip) (City,State,Zip) ESetba <br /> Setbacks <br /> PHONE PHONE • ❑ Site Plan a oval from <br /> pplica township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> El plans to scale <br /> PROPERTY/LOCATION;INFORMATION ':(http:Uaccessdane:co:dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRE TZONING: ACREAGE: El ation of property <br /> ❑ PARCEL (� 1 alca .o�,95j ` J 3.3 QCt`t onta <br /> NUMBER Q � ge drawn to scale. <br /> TOWNSHIP: SECTION. /\J <br /> S pc 1 d�Q (p /: S D iveway permits <br /> ADDRESS: • <br /> tate,county,town) <br /> CQ001/4t1 Sanitary permits <br /> CSM: I 'q�� LOT A a SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> _ PROPOSED PROJECT INFORMATION: A <br /> �y T -4 <br /> PROJECT DESCRIPTION: 'N, 1 .Fx 1 £ . 4' <br /> r <br /> 51 ! - • ■ IA Q. •r ti u 4, 1� Aa t0.fisa �` � F <br /> .K,This project is a new but ding or st ture. € <br /> ❑This project is an addition/alteration to an existing building or structure. ¶C) t C- � m1 s ; , <br /> SANITARY SERVICE: PERMIT NUMBER: a a a -7. - <br /> ❑SEWER tJLSEPTIC I • a 4 M is =x, <br /> HEIGHT IN FEET: b NUMBER OF STORIES: (Not including basement) rr - <br /> AREA TO NEAREST SQUARE FOOT: ��� ° � s <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) l . <br /> BASEMENT: l 1ST FLOOR: ;, e 6 s0�:A <br /> 3 /+ I ,l, TOTAL SQUARE FOOTAGE: 4, . , - � t <br /> 2ND FLOOR: r J j 3RD FLOOR: a ;1,77.--:-::::=. <br /> ESTIMATED CONSTRUCTION COST � P a f itt(Please round to nearest dollar) —O. '♦ "∎ "♦ '♦ $ p �4o D 0 O . 0 b <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes lNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Utlo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1iiiYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes eifNo <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 ®'NNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes allo <br /> APPLICATION MUST BE SIGNED <br /> 545.112(4/06) (Continue on Back) —► —► —IP. <br />