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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION 1,':„, ...; # i&;h .. ,. '? CUSTOMER TO PROVIDE <br /> O/WNWR NAMME ) -� <br /> L�.Ji (1 FC ecZ. ( r(C-k- ❑ Zoning Status;CUP; <br /> OWNER ADDRESS umber,Street,City,Frtetp,Zip) <br /> /� /� Deed Restriction;CSM <br /> ` &/ C L,/ f� �,5i` Variance(# �S°I-G ) <br /> HOME PHONE C LL PHONEO2 _f E-MAIL P JDRESS l <br /> &0ic;f: + •■ 0-4-7. Z •rr.. L -.! C! , is• A 01 Site Plan drawn to scale <br /> AGENT INFORMATION:`. , CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ( T t�lf/' pfd I ,(Si P n including location 2 (AGENT ADDRESS 7 COtrT TOf�7C�D�ESS of septic <br /> C •(City,Sta:,-'• ' (Ci Statpq,-zip) ❑ Set r ks J4-r�,c' <br /> PHONE PHONE C IE Site Plan approval from <br /> 7 '1-3°. -- applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ili> L • '6 • Floor plans • - .le <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi,usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: �r�jy CURRENT ZO ING: ACREAGE: P P rty <br /> ❑ <br /> NUMBER rl2- 1 57°� 42LI- )r-1 sl I -A rontage drawn to scale <br /> TOWNSHIP: SECTION: <br /> A-Z1010 n 1 v 0 ,/: �S E_ %%: 5r -: Dri e y ermits <br /> ADDRESS: ✓1 V (state, nty,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT n Sani _• per Its <br /> .ubliate) <br /> PROPOSED PROJECT INFORMATION .� '` <br /> PROJECT DESCRIPTION: r - <br /> I C. .0- .r ' nC)X -s a r > , ° <br /> • C]This project is a new building or structure. a - � 5a &- <br /> . <br /> This project is an addition/alteration to an existing building or structure. - <br /> SANITARY SERVICE: PERMI UM: R: F ` I +i- <br /> ❑SEWER r SEPTIC ,ffi�' �-t/, :. " f` .• ¢ h <br /> HEIGHT I i NUMBER OF 'ORIES: (Not including basement) , �' ,„ �tf--' . � <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) .:7,...54,t, -44-' -.,f, - . , <br /> BASEMENT 1ST FLOOR: ���,® °�r� <br /> S/ ^ ^ 4, TOTAL SQUARE FOOTAGE: 4, "` - - ? O s. .- <br /> 2ND FLOOR: 3RD FLOOR: h-4 <br /> 'Si 0 o itit S oy P..a ki frl^:- 6 <br /> ESTIMATED CONSTRUCTION COST: � "° ° I 1-(Please round to nearest dollar) QQ , _...K4 ,$, v _--', <br /> , _ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes t•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? tig,Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? t 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) CI Yes ❑No 0 Don't know <br /> 7. Is this to correct a violation? ❑Yes g.No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(alon) (Continue on Back) -i -► -♦ <br />