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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION ,; ,•K =; '„ tom; - ,r ,.x,_. • t ?;_ -`,;. CUSTOMER TO PROVIDE <br /> + <br /> OWNER NAME <br /> ❑ Zoning Status;CUP; <br /> OW SRS per,Street,City,State,Zip) , .I �-��,r,,� Deed Restriction;CSM <br /> O�j �, "A ``_ '�''f� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION ;: CONTRACTOR JNFORMATION r• 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) LI 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.usn ❑ Elevation of property <br /> PARENT P C NUMBER: �%/ U RENTJONIN/ ACREAG P P rty <br /> ❑ NUMBER 5 2 —2v / �� 3D r( /, �_ 7.N frontage drawn to scale. <br /> TOWNSHIP: m SECTION: / <br /> e et.',, , Z sS ,v: NE 1/1/. (v h/ ❑ Driveway permits <br /> ADDRESS: �J (state,county,town) <br /> ` L v Q 'O T'r`" ❑ Sanitary permits <br /> CSM: 9 j (RS LOT / SUBDIVISION BLOCK/LOT <br /> 9 (public,private) <br /> PROPOSED PROJECT INFORMATION r :: . , I <br /> T "§PROJECT DESCRIPTION: <br /> 1 fallarill11.111111krAtirW14-7-1"'kl' ...,.=,,-. 0-..--.. <br /> A This project is a n, buildin0 or structure. [4,'- -'s Y -^ <br /> ❑This project is an addition/alteration to an existing building or structure. - t ' <br /> SANITARY SERVICE: r PERMIT NUMBER: :A-.z:: 4 . °1- <br /> ❑SEWER & EPTIC v <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) o .- <br /> _ ® YR t <br /> AREA TO NEAREST SQUARE FOOT: V. ti <br /> (Outside dimensions including unfinished area,attach-d garages and above grade decks or porches) �` r <br /> BASEMENT: 1ST FLOOR: .Ir� �m � ® m � �� ®� V <br /> TOTAL SQUARE FOOTAGE: 4, - _ s •24-iiit , ,--. <br /> 2ND FLOOR: 3RD FLOOR: 1 � <br /> 5:; �ESTIMATED CONSTRUCTION COST: ► -+ -* -* —► $ V © ® o ,2 <br /> ,(Please round to nearest dollar) J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI 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? LI 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 /> .0:-.--- 1 )o?, P 0 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —p —► <br /> 545-112(4/08) <br />