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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER;INFORMATION;r.;;: <br /> 1.1•' ,4 00_ °.' `, -- .-<' CUSTOMER TO PROVIDE <br /> OWNER NAME /1 <br /> ❑ Zoning Status;CUP; <br /> OWNER If DRESS (Number,Street,Ci4y,State,Zip) Deed Restriction;CSM <br /> .9'7 6'7 0 �,rt lam) Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDR SS <br /> al- -5.8%.- 24/Q f Sov>•)Ov 5 Q <br /> D, C m . ❑ Site Plan drawn to scale <br /> AGENT INFORMATION,;. , CONTRACTO4]NFORMATION 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) ❑ 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.danewi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P Y <br /> ❑ NUMBER G/6 2- 0 S 3 0030.1 2c4,. frontage drawn to scale. <br /> TOWNSHIP: SyTION: /: w 1/4V: N CI Driveway tD1 <br /> (state,county,town) <br /> ADDRESS: <br /> 1661 01-4 q, ❑ Sanitary permits <br /> SM:•0.‘t LOT SUBDIVISION BLO�K/LOT <br /> /-11. (public,private) <br /> PROPOSED PROJECT INFORMATION m`' °" pp <br /> PROJECT DESCRIPTION: � ' <br /> • ❑This project is a new building or structure. 2 1... rt € ;r l <br /> -4 This project is an addition/alteration to an existing building or structure. - � � <br /> SANITARY SERVICE: PERMIT NUMBER: '� ')� °° "'` <br /> ❑SEWER SEPTIC a v' � -•HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) . _ � � -' <br /> a <br /> 8 .. S Pe'S+ t <br /> AREA TO NEAREST SQUARE FOOT: w '- e <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,., ' ° <br /> BASEMENT: 1ST FLOG �e ° ° ® <br /> % j TOTAL SQUARE FOOTAGE: 4, e ,.st °* �0. <br /> 2ND FLOOR: 3RD FLOOR: ` <br /> 94;01 F �=off€ i. <br /> ESTIMATED CONSTRUCTION COST: # ° d'°3° <br /> (Please round to nearest dollar) JO co-, ��� 14��d�� �-i-�2.. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ! # o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes IG No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes VNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 4No <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 El No Don't know <br /> 7. Is this to correct a violation? ❑Yes 14No <br /> APPLICATION MUST BE SIGNED <br /> Z (Continue on Back) --► -► -■ <br /> 545-112(4/08) <br />