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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web..App# <br /> PROPERTY OWNER:INFORMATION', .. 11.440...: ,:::-.,', '="',--.'•, •= CUSTOMER TO PROVI E <br /> OWNER NAME ' <br /> X Zoning Status;CUP, �j2 <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM r '4f J <br /> Variance(# ) <br /> H• ,P-•t z/ PHONE E-MAIL ADDRESS <br /> A 7 / ❑ Site Plan drawn to scale <br /> AGENT INFORMATION - CONTRACTOR INFORMATION _= ,_ s 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) g Setbacks /°°6/21 Z ` �o <br /> 0 <br /> PHONE PHONE jJ J Site Plan approval from <br /> t 1 fAILADTSS) \applicable township:E MAILADDRESS I /^ �� t/ <br /> \J �J -� Floor plans to scale <br /> PROPERTY/LOCATION N;INFORMATION 4;(http:l/accessdane:co.dane.wi.usl),: .. =`I: Elevation of property <br /> PARENT P C L MBE CURRE ING: ACREAGE: <br /> ❑ PARCEL �y, � —�� /� Z 3, z frontage drawn to scale. <br /> NUMBER / / <br /> TOWNSHIP SECTION: /1/. w / <br /> Cr'o �-� G v a � 3 3 1/4: 1/41/4: Sh/ )�' Drivewa •-rmit Ii <br /> ADDRESS: (State, • 17'3 / 0 C T H ki <br /> v Sanitary permits /17 'I' <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION, y <br /> PROJECT DESCRIPTION: A � ��� ������ - �� �� �� � ���^ � a��� <br /> 40 es S /6X-/ Z—A /2— a- - 2- <br /> 1rhisprojectis . R ew buildin• •r structure. a- m W '' `- 1 <br /> ❑This project is an addition/alteration to an existing building or struct re. = ., s N G� 1 <br /> SANITARY SERVICE: PERMIT NUMBER: , <br /> h -- ' It 4a' - <br /> / <br /> ❑SEWER IV SEPTIC 3� �� <br /> HEIGHT IN FEET + l • NUMBER OF STORIES: (Not including basement) <br /> -** '� - <br /> AREA TO NEAREST SQUARE FOOT: :,,,F k �-. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> IR R <br /> ,, TOTAL SQUARE FOOTAGE: ,, <br /> 2ND FLOOR: 3RD FLOOR: ` F � a <br /> 2ND FLOOR: 3RD FLOOR: / <br /> �1 a�r tip- a -,4 ,(Pleasne rouDnd tto nearestt do110;COST: -.► -i --► ♦ -► --I• $ ® ®9® iit_J <br /> 1. The property is within 300 feet of a 1000 fe- from a pond or lake? ❑Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes eK-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 NNo 9 2^ /7/1- <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 tVo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -o. <br /> 545-112(4/09) <br />