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ZONING PERMIT APPLICATION www.countyofdane.com ;SUPPLEMENT=to Web•App#. <br /> PROPERTY OWNER INFORMATION ki Y=,' ':i 4 44: s, ; ;, Q, )._^"' CUSTOMER TO PROVIDE <br /> OWNER NAME p 6 , <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS f umbetreet, ity,State,Zip) M / ',� J Deed Restriction;CSM HOM �C � S � �7R✓t 5 7 ' lG 4 r t �lit� V l Variance(# ) <br /> OP���'�0�3 CELL PHONE E-MAIL ADDRESS�0/5 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR;INFORMATION:I 4, -' 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) ❑ 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 'Ahttp://accessdane co dalne vi usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 0 6 t a o l 3 99?-4 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: ��� SECTIO t. / <br /> p D 1/: S W ,%,A. $ 1,f ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT q g SUBDIVISION <br /> lik �� /-1-1 BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION i . „r" • S <br /> PROJECT DESCRIPTION: y -ot & <br /> This project is a new building or structure. , , <br /> ❑This project is an addition/alteration to an existing building or structure. 1- _ -$ <br /> SANITARY SERVI9: PERMIT NUMBER: 1 tl a 'N'f �1 <br /> 'CJ SEWER ❑SEPTIC N `, e�N/exis I g r O <br /> HEIGHT IN FEET/ ` NUMBER OF STORIES: (Not including basement) : ' <br /> `/ / , <br /> f" f1orel+ ft r. ent <br /> AREA TO NEAREST SQUARE FOOT: a i -f-, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) di., •_ <br /> BASEMENT: 1ST FLOOR: Z ® ° ® , <br /> Ire 1 Q 4, TOTAL SQUARE FOOTAGE: ,l ,:'. 'I n- <br /> 2ND FLOOR: 3RD FLOOR: — <br /> Pi D ESTIMATED CONSTRUCTION COST: 0 , <br /> (Please round to nearest dollar) "� "♦ '� ♦ ♦ ©� . a � <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 /> /g APPLICATION MUST BE SIGNED <br /> 545-112(4/08) J (Continue on Back) --0' —10 --0. <br />