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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> d"h v. a`e L ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> /3 5S7 wetk e 1,1 B e.,.•1/-e./ w= 53 5' ' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> bob y17—Sf58 'oil_V~'e` C a yaLoo.r°'"'' ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION 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.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL _ ci .� a frontage drawn to scale. <br /> NUMBER oy�/s411-�11 8691-0 �9. 97� <br /> TOWNSHIP: SECTION: <br /> Pleac w1f f5ril t ys: %oh: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> only Gltr,n art IT/ SW acilvii„, u'S `159 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ST <br /> PROJECT DESCRIPTION: < \ <br /> This project is a new bhildin or structure. <br /> ❑ P 1 9 U . <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 1.+�1(� Runi Address <br /> FIEWER r)EPTIC {new tingr 'r <br /> Ee <br /> HEIGHT IN FEET Y 1( ( NUMBER OF STORIES: (Not induding basement) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: to <br /> 4, TOTAL SQUARE FOOTAGE: , f ', <br /> 2ND FLOOR: 3RD FLOOR: V `' • <br /> *trey <br /> ESTIMATED CONSTRUCTION COST: '♦ ♦ ♦ ♦ --0. <br /> (Please round to nearest dollar) $ /0 Q v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes o ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Yes Vo <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 o ❑Don't know <br /> 7. Is this to correct a violation? [Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -♦ <br /> 545-112(4/08) <br />