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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION <br /> v�o� _ ` CUSTOMER TO PROVIDE <br /> r o 1RI IA ��1a�@� L.,\��� ,s+ aNy <br /> ❑ Zoning Status;CUP; <br /> OWNER ADD S ( umb @r,Street,City,State,Zip) (� . l \ ` ' Deed Restriction;CSM <br /> 5 (1 vNAI� \(� � �I C�L1�(` 1�t`�� �1 � Variance(# ) <br /> ,H‘PH PH`E �� CELL PHONE E-M ''RESS <br /> ��� s S'-'15i1% <br /> f� kkt\o 11 ll■k LI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME ONTRACTOR NAME <br /> 5aM Q,r 1 �r '��t\�� �c/w \\N{\AQY,n`���1� ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS ` of well/septic <br /> (city, tate.Cp) \k ' \\ � S ry state,zip) ❑ Setbacks <br /> PHON \v1/41 ��� a jCJ�`(_ PHONE ❑ Site Plan approval from <br /> (� ��' applicable township. <br /> E-MAIL Aq S E-MAIL ADDRESS <br /> tt \ 0 At gd►\1\ 7)1 CI ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http:l/accessdane.co.dane.wi.us!) <br /> PARENT PARCEL NUMBER: �CURRENTZ�O,�NIING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER 04$ `^'FO (14 gQSo "�{. >� , t.x ,,1 O frontage drawn to scale. <br /> TOWNSHIP: V SECTION: ❑ Driveway,/: ,/,/: ypermits <br /> ADDRESS: (state,county,town) <br /> �� <br /> sc:\ MtSs\Q\nt'\\ Ck ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION :1 :751-11 <br /> PROJECT D SCRIP IONS � <br /> / , z a - . <br /> . ❑This project is a new building or structure. , � <br /> ' �°: <br /> This project is an addition/alteration to an existing building or structure. .� <br /> , jv..i•::,-;_,-,=- �:'-' fiF.2 �: �'4'§r <br /> SANITARY SERVICE: PERMIT NUMBER: Tt 9 <br /> ❑SEWER %EPTIC s a �. I <br /> = rte � <br /> HEIGHT IN FEET: 2 NUMBER OF STORIES: (Not including basement) „ <br /> ti <br /> AREA TO NEAREST SQUARE FOOT: -:- <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: - n' e1 <br /> �—'- S 0 j TOTAL SQUARE FOOTAGE: 4, 1 °_,q £ ,,1k, <br /> 2ND FLOOR: 3RD FLOOR: ,1 W' _'S' <br /> a ,,` - � . <br /> ESTIMATED CONSTRUCTION COST: li 0 . <br /> ( ) .+ ♦ -► ♦ -♦ _+ $ -' a , s <br /> Please round to nearest dollar S © - : x <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 0 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 0 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 ®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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 0 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ -► <br /> 545-112(4108) <br />