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ZONING PERMIT APPLICATION www.countyofdane.com ;SUPPLEMENT to Web-App#. <br /> PROPERTY OWNER INFORMATION.:,, z'_ '_�� ,110,;_: ,,r._s< z, '. <br /> OW ER NAME CUSTOMER TO PROVIDE <br /> tcha,rd L K' i ' <br /> OERADDRESS Number Street City, Yate i El Zoning Status P; <br /> �y 5 ,f / / I(Number, } y) Deed Re( tion;CSM ) <br /> ` ( �` ari e # <br /> H ME PHONE CELL PHONE E-MAIL ADDRESS <br /> 4-0r f 7.5 )1)? Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION 4":.,,.! 1 and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f well/septic <br /> (City,State,Zip) (City,State,Zip) 41 Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usa <br /> PARENT PARCEL N MBER: CURRENT ZONING: ACREAGE: Elevation of property <br /> ❑ PARCEL a�O6 — 0/3- 00 1-/� n- ' /.. f� frontage drawn to scale. <br /> NUMBER t� 0`1 h-� <br /> TOWNSHIP: SECTION: �- <br /> • r-e ,s I 1h: S lip) 1/1/. N ' ❑ Drivew ermits <br /> ADDRESS: (sta ,county,town) <br /> / tS q ).< ee I/e c � 1 ❑ Sanita ermits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (pu c,private) <br /> PROPOSED PROJECT INFORMATION; i . <br /> PROJECT DESCRIPTION: Y s a <br /> l 4 1� -:° rx t a R L i <br /> e <br /> This project is a new building or structure. ' ' <br /> ❑This project is an addition/alteration to an existing building or structure. r , , <br /> SANITARY SERVICE: PERMIT NUMBER: !°3e a r '" <br /> ❑SEWER II SEPTIC " � ,,e <br /> HEIGHT IN FEET: NUMBER OF STORI(iS: (Not including basement) =,-.„,'-',„A <br /> We IIS s3��'. 2 ° �,eqi : E� <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ` . ,;,, <br /> ����r � <br /> BASEMENT: 1ST FLOOR: k� � ''J'. <br /> ,, TOTAL SQUARE FOOTAGE: 4, 4 - i a0:- e 4! <br /> � ! „ <br /> 2ND FLOOR: 3RD FLOOR: 1 r <br /> ESTIMATED CONSTRUCTION COST: � W ® 1%Please round to nearest dollar -► a t a 4,-, , <br /> T <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L' oo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes l�!'No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑ es LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? bA Yes ❑N <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan f none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -0' —0. -0' <br />