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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNEIAME <br /> n4-G i J. Wi L L el-12 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Numbs/NSSttre�ett City,State,Zip) jV� /�y�`'� ` Deed Restriction;CSM <br /> HOME E 3 CELL PHONE GZ E-MAIL ADDRESS WI 53.c S. Variance(# <br /> 2 J7. 443b *�Kait: Sll-sry v cfp nuic. /��� <br /> �I'l Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Li EleVatlOn of property <br /> PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> • <br /> • 'E7 This project is a new building or structure. � <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: °°� <br /> ❑SEWER ❑SEPTICj f� � <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) -• • <br /> ae <br /> 9L <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> ® * 44A <br /> BASEMENT: 1ST FLOOR: - <br /> 4 TOTAL SQUARE FOOTAGE: ,��(",15 <br /> 2ND FLOOR: 3RD FLOOR: <br /> Z. �d <br /> ',1 <br /> ESTIMATED CONSTRUCTION COST: QQ�� <br /> (Please round to nearest dollar) $ �O O <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? ❑Yes 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 J 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 ''E7 No ❑Don't know <br /> 7. Is this to correct a violation? NO Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545.112(4/08) <br />