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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> k0C S . 114 c' COGLIKJ c ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number`,Street,City,State,Zip) <br /> n 6 /J IV1 C 1-� Deed Restriction;CSM <br /> � Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Z 3 - gar ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME A FA/4-r <br /> i7 37 Oaf i-7-6/04-6C dccijJc -i >h./--T r9emalij ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 38/S- c<J4-s-64- >f 6?.v,v /WE <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PH/ONE/(4iSt 1� ( I 5370 y ❑ Site Plan approval from <br /> 6(A ,z�t 36 applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 8C5ir— ti-c---m(4-14CH,r ,LAU Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.ciane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • <br /> /4; <br /> 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: ° e-T, ,` <br /> . jiiiJhis 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: °.�° ,.r � <br /> ❑SEWER ❑SEPTIC .iti° ° , -, <br /> .,— - a , <br /> HEIGHT EET: NUMBER OF STORIES: (Not including basement) m t ' •1 <br /> AREA TO NEAREST SQUARE FOOT: u ® � r�g <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � s <br /> BASE NT: 1 T FLOOR: ' , ® � i` <br /> / / --7 a Q 4, TOTAL SQUARE FOOTAGE: 4, d. , . a�,4 i <br /> 'VVr�/ O a';,sat" . 4 <br /> 2ND FLOOR: 3RD FLOOR:/110)/0, --- ^/ ( wk,, <br /> ESTIMATED CONSTRUCTION COST: 7 d° i v <br /> v - : <br /> (Please round to nearest dollar) "� ������ �� ' <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes gi No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes J No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 1CJYes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I 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 0 No ..Don't know <br /> 7. Is this to correct a violation? ❑Yes El No <br /> APPLICATION MUST BE SIGNED <br /> 545.112(4/08) <br /> (Continue on Back) —11. —► —► <br />