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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWN(�`R�NAAgME <br /> `" I CL.( r `,- O(q T0r` ❑ Zoning Status;CUP; <br /> OWNNEER/A,DDRESS (Number,Street,City,State,Zip)�i t -I n (� ` q Deed <br /> I Lj(p 1 �A4PQ-41 /A'l"6 U1/-1'f 95O\ OL 53 /'99/1p Variance e(ttriction;CSM ) <br /> NOME PHONE CELL PHONE / E-MAIL ADDRESS/f0, 8((,'30 0 'i(r er tJ CYf #. '(1/1 © Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME / (� C NTRACTOR NAME <br /> �t)Z e/// ' L $GU(S s 5 _ r c . ❑ Site Plan including location <br /> AG NT ADD S CONTRACTOR ADDRESS of well/septic <br /> 1116)- ► 41 Lane 3/0 b2CU,'r © 6 . <br /> (City,State,Zip) (city State,zip) ❑ Setbacks <br /> IA)r�� 53 �99 1/ �a I X359.3 <br /> CPE / P-. ( ❑ Site Plan approval from <br /> S) g L{6- 4(0° x-%f /'1 0 i Yo ' applicable township: <br /> IL ADDRESS E- ILADrRESS <br /> /`,p�- v C6AG ge,,, i1 I /RS b(AS s r is, , ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • <br /> '/a: 141/4: LI Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION 9r <br /> PROJECT DESCRIPTION: s'§,v 4 <br /> ICU❑This project is a new building or structure. '- i 4� i,� <br /> ❑This project is an addition/alteration to an existing building or structure. #-K . <br /> SANITARY SERVICE: PERMIT NUMBER: L" ��e o - <br /> �e <br /> ❑SEWER ❑SEPTIC <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) , �� <br /> ,,��--,`a <br /> ® - C �k <br /> AREA TO NEAREST SQUARE FOOT: 4 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) L Y� �, " £,,r <br /> BASEMENT: 1ST FLOOR: ®1 a s a <br /> 4, TOTAL SQUARE FOOTAGE: 4, ` <br /> *_{..,,t- 'i a r: <br /> 2ND FLOOR: 3RD FLOOR: ,I •, . - <br /> § `ESTIMATED CONSTRUCTION COST: . , <br /> -► -► -. -► -► -► $ a 'a(Please round to nearest dollar) 0'4)° <br /> fl <br /> r <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or la e? ❑Yes FiNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes gNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Ai-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 /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -* <br /> 545-112(4/08) <br />