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, <br /> .S'S <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME, <br /> WO OWNER ADDReSS (N ber,Street Ci t' ,'Z z_eic Zoning Status;CUP; <br /> Y7 t , f Deed Restriction;CSM <br /> HOME PHONE CELL PHONE ariance(# ) <br /> E-MAIL-MAIL ADDRESS <br /> 2 e--' Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION aid includes dimensions <br /> AGENT NAME _/ / CONTRACTOR NAME <br /> /� L/i �y'P(41r-c0 Yl<(CI IL ;3 am() ite Plan including location <br /> AGENT AD ESS CONTRACTOR ADDRESS bf well/septic <br /> soleilas 6/r • <br /> (cty,State,Zip) // r (City,State,Zip) Setbacks <br /> PHON ! `L/` 3��� <br /> PHONE i e Plan approval from <br /> 6 C18 S92 623 S6 pplicable township. <br /> E 'IL ADDRESS // E-MAILADDRESS <br /> k 1 rd / (P(YC� -Ccrak. .,Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usr7 <br /> PARENT PARCEL NUMBER: CUVENTZONING: ACREAGE: 5 Elevation of property <br /> Li PARCEL ^� ,/ / N / Z k ' 7 ontage drawn to scale. <br /> NUMBER Q7�� �'7�" �l(CjS'- l f <br /> TOWN IIPP: /� SECAI? <br /> AD §: t2? L7�2'e l U '/4:__11 '/a'/4: Driveway permits <br /> (state,county,town) <br /> CSM: 7� ��LOT-71 rd A•SUBDIVISION BLOCK/LOT anitary permits <br /> public,private) <br /> PROPOSED PROJECT INFORMATION a <br /> PROJECT DESCRIPTION: / L--,,,,',1-.--'!- <br /> —C'CPcy∎ P9(Cl� ) 0Xip y <br /> ❑This project is a new building or structure. <br /> ice_ '' 10q = -- <br /> , This project is an addition/alteration to an existing building or structure. <br /> 1 r-_. . t <br /> �-0 <br /> _SANITARY SERVICE: PERM1INUMaER_� ,--,.1,',-.i,= 'e o c : � <br /> ❑SEWER 6:4 SEPTIC }a ',a <br /> - --0,,,,',:,- <br /> w HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � , �a] � D �el, a <br /> rti <br /> AREA TO NEAREST SQUARE FOOT: : "- "Q � " - <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: �_ sa4 <br /> 0Q TOTAL SQUARE FOOTAGE: g 4" .i € �,� , <br /> 2ND FLOOR: 3RD FLOOR: Y a ® " -tb <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ""o. -4. "� -4. -+ $ / 0 0 . B -I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 91 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EINo ❑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 -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) ❑Yes - o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes - .No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) ■ -► -► <br />