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• <br /> f ) ) <br /> • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME Da <br /> g/cka„j �__ '-9 ► oning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Restriction;CSM <br /> 69'2 /na t/,� G6z.1e S',,,, pia.,%,€ it)/ 53,;90 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> $2S- 6509 R )p4 "drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION cludes dimensions <br /> AGENT NAME / CONTRACTOR NAME <br /> Amen can ha✓s+ /'v,i ii/5 • ite Plan including location <br /> AGENT ADDRESS �cJJ CONTRAC ADDRESS of well/septic <br /> 54. 4:-re ft Air, Dr. <br /> (clry,State,Zip) (city,State,Zip) • -tbacks <br /> 5.,” Pik,;7e A// 5-3510 fi PHONE PHONE Site Plan royal from <br /> 400$ - yYv-f77 3 applic a township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> • or pl s to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) I <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACRE E: '' Elevation of property <br /> ❑ PARCEL _/Iv �� frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: , / �►�I <br /> ,'at01 "l 1/a: N W '/41h: t� , ,Driveway permits <br /> ADDRESS: / (state,county,town) <br /> 63`/Z-- W Gi-. �✓airi' wl �3J�D ' Sanitary permits <br /> CSM: OT S SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION b #r: d ? <br /> ' . <br /> PROJECT DESCRIPTION: ,x : �s '. A <br /> . 'C this project is a new building or structure. Y. - ;. ,.,e <br /> ❑This project is an addition/alteration to an existing building or structure. ' <br /> � , <br /> SANITARY SERVICE: PERMIT NUMBER: ° �� e aii � ' <br /> SEWER SEPTIC ~/� - a a�.caia r. 3 -k. <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> /IV" ) 1 / :pia" 1- I'" '/` ` <br /> AREA TO NEAREST SQUARE FOOT: � ° <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) .' , <br /> BASEMENT: 1ST FLOOR: � � - Z; <br /> 4, TOTAL SQUARE FOOTAGE: r-s , �' ,� <br /> 2ND FLOOR: 3RD FLOOR: ` <br /> L t '� ��n,,' � Z Vr P k i - <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ -► ♦ ♦ ♦ m _ z <br /> (Please round to nearest dollar) /��4D 8 . fr� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes IS 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 ®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 ®No <br /> A B► <br /> (Continue PPLICATION on Bac )MUST k -E -►SIGNED <br /> 545-112(4/09) <br />