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►b <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER N JA E c7 IS o <br /> V ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number, reel,City,State,Zip) —yam Deed Restriction;CSM <br /> 0 �6 ���� C ( G7-� j Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (;fit- 1:33-q 7 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> j'T NAME CONTRACTOR NAME <br /> `jf9,*J, . 45 QG(J/Ut c ❑ Site Plan including location <br /> TAD DRESS 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.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 'G+. i _54.7 j <br /> NUMBER F- , frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /1/1,imp/e z2 _ 1/d_ 1/1/4, ❑ Driveway permits <br /> ADDRESS: ( 1, l� (state,county,town) <br /> 7?s6 Loss C-1— ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> at i,!Ate // (public,private)td <br /> PROPOSED PROJECT INFORMATION �/ . E <br /> PROJECT DESCRIPTION: ` F p <br /> GG1qcF bpi o� 1-3 <br /> . ❑This project is a new building or structure. 4 <br /> This project is an addition/alteration to an existing building or structure. _ <br /> SANITARY SERVICE: PERMIT NUMBER: eti3 „ . 7 <br /> ❑SEWER SEPTIC <br /> HEIGHT IN FEET 1—�L ��„! NUMBER OF STORIES: (Not including basement) <br /> (/ . az g iii' '1 <br /> AREA TO NEAREST SQUARE FOOT: y P. <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) l <br /> BASEMENT: 1ST FLOOR: / 34° " <br /> ©� �O ,, TOTAL SQUARE FOOTAGE: j .t 1 w 'q' <br /> s ,. a, ..a <br /> 2ND FLOOR: 3RD FLOOR: far ¢ <br /> 1/620 • �— <br /> ESTIMATED CONSTRUCTION COST: 9av a> <br /> a . <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? ErYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ntNo ❑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 Vivo <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 i o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes -14176 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► —► <br /> 545-112(4/08) <br />