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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 /> `� h n 4 `"l <br /> f4:5-4- <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> S-89-2,2 / y ,87.05 a/A/, 1/l S . -/ Variance(# ) <br /> /HOO'ME PHONE / CELL PHONE E-MAIL ADDRESS <br /> 64-C/S5 Y'2? 6.0Y-y36.giro G6,yt d: dd_ c_ . ❑ Site Plan drawn to scale <br /> AGENT INFORMATION 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 LI 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.chane.wi.usn <br /> PARENT PARCEL NUMBER: CURRE, TZONING: ACREAGE: ❑ Elevation of property <br /> 0 PARCEL _� frontage drawn to scale. <br /> NUMBER OSl p-- /Qy— S/J--t) /t <br /> TOWNSHIP: SECTION: <br /> /2 ie-t 1 ? ,/: SC--7 1/1/. -'c= ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> S-67,72 14y /y 8496ez 4viv k/r S-3s� / ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION g � x' 3 <br /> PROJECT DESCRIPTION: <br /> Yt(1 ya/ CC 4:53225,5 dy Ju L�� K Q, • <br /> f � <br /> , <br /> El This project is a new building or structure. � 4 �� , � . <br /> ❑This project is an addition/alteration to an existing building or structure. , : �-� <br /> Wi' F 3 9F4 wit <br /> SANITARY SERVICE: ~ � s <br /> PERMIT NUMBER: I. � � ,� gf`; <br /> ❑SEWER CI SEPTIC A '- -` -2 <br /> HEIGHT IN FEET: NUMBER OF STO-IES: (Not including basement) � <br /> AREA TO NEAREST SQUARE FOOT I�r: � ' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � a <br /> BASEMENT: 1ST FLOOR: ® � V��a° <br /> 70� 4, TOTAL SQUARE FOOTAGE: 4, :�' € . , i3, �� <br /> 2ND FLOOR: 3RD FLOOR: fir ,4, a <br /> 7vV „. <br /> ESTIMATED CONSTRUCTION COST: , <br /> ♦ ♦ ♦ --► --► ♦ - a q s a® � <br /> (Please round to nearest dollar) ( 0 000 �` � <br /> I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes EfNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 4 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? alYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? tit 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 /> 3 <br /> C %- D MUST BE SIGNED <br /> 545-112(4/08) 2 , 9- (Continue on Back) —► —► —► <br /> J <br /> I <br />