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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION ;:? .... x',' 1 " ... ,.. CUSTOMER TO PROVIDE <br /> OWNER NAME 5 <br /> JJ c) b of v (,‹:,;. ►% Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip <br /> Deed Restriction;CSM <br /> a ( Q 4 S S c, l<f, (--E- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 49s-66r? b i" j t`" fr`2 `=J v'A c.C, Cam'"\A ,. C Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION F / 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) /M Setbacks <br /> PHONE PHONE Site Plan pproval from <br /> applic a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.danewi.usl) <br /> PARENT PARCEL NUMBER: CURRENT ZONING' ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 65)6 '4 I O ` O R_I f —a : G a frontage drawn to scale. <br /> NUMBER / <br /> TOWNSHIP: SECTION: <br /> R 4 1,,, QA 0 9 ,/: N. 1:: ,/,%, 1U ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: I <br /> ~f S ( B a s S Lq k CI- ❑ Sanitary permits <br /> CSM: LOT { SUBDIVISION BLOCK/LOT <br /> I (public,private) <br /> PROPOSED PROJECT INFORMATION W ' <br /> PROJECT DESCRIPTION: r fat <br /> 11 X'1't 51‘ e (i-e f -(Dv- \l/ok _c-{ ov ca J '7111p.f 0 '°x, , : <br /> DA This project is a new building or structure. .. s . - <br /> ❑This project is an addition/alteration to an existing building or structure. ''. <br /> � �� . <br /> SANITARY SERVICE: PERMIT NUMBER: 7:.I. =.'r <br /> ❑SEWER ❑SEPTIC I till <br /> HEIGHT IN FEET. / / NUMBER OF STORIES: (Not including basement) x <br /> It 0`� ei 'aa:�, f)I;i s6 ' <br /> ® 11s t Fr s.s ' h` <br /> AREA TO NEAREST SQUARE FOOT: �_ f : <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) - � <br /> °, 1 -, <br /> BASEMENT: t ST FLOOR: 1 4VO �� a':,`` <br /> TOTAL SQUARE FOOTAGE: � � "�.,�" �� <br /> 2ND FLOOR: 3RD FLOOR: � � � � '� <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ 4;0� o n °e t k,;' <br /> QQ�� <br /> (Please round to nearest dollar) �P z- <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? LI Yes ❑No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Ed No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 0 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) 0-Yes ❑No S-Don't know <br /> 7. Is this to correct a violation? ❑Yes friiNo <br /> AIAUT E IG <br /> 545-112(4/08) (CoPPLntinue C on TION BackMS) B—►S—►NED-♦ <br />