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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 /> ST4e y ,,M/4I2z ❑ Zoning Status;CUP;
<br /> OWNER ADDRESS (Number,Street,City,State,Zip)
<br /> 33'0 G/51�C'�c'Ha4 e j)2 EP6-e-Rre - Deed Restriction;CSM
<br /> Variance(# )
<br /> HOME PHONE CELL PHONE E-MAIL ADDRESS
<br /> do8'ggq g6y) let g y ST'9Cs YigsLeti¢ez-egemeree•'"t" ❑ Site Plan drawn to scale
<br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions
<br /> AGENT NAME CONTRACTOR NAME
<br /> a 4/,01/ 2- ❑ 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.ciane.wi.us/)
<br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property
<br /> ❑ PARCEL /1-2c9-10 Q frontage drawn to scale.
<br /> NUMBER �� 'g 3 2J? g
<br /> TOWNSHIP: SECTION:
<br /> 4 tg/0g/ IA: 1/1/4: ❑ Driveway permits
<br /> ADDRESS: (state,county,town)
<br /> 35-0 tAee-C1/O(t Pk e-i G `e 7-1 ' ❑ Sanitary permits
<br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private)
<br /> e-,o&exPine/ifardyst
<br /> PROPOSED PROJECT INFORMATION 1 -,,,
<br /> PROJECT DESCRIPTION: ,, - —
<br /> EL F1/4-Tt` /L,i 'cc - ri e � �
<br /> ❑This project is a new building or structure. !;;;,-„,,,:.,-, _.. :,,,,t„-„,,,,,
<br /> NI This project is an addition/alteration to an existing building or structure. ;`:` �
<br /> SANITARY SERVICE: ' - e a t
<br /> PERMIT NUMBER: �� a„� �}
<br /> NI SEWER ❑SEPTIC '"2 ` E" a '�
<br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �' � ;
<br /> AREA TO NEAREST SQUARE FOOT: , q,
<br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) a °
<br /> .a e
<br /> BASEMENT: 1ST FLOOR: - , i ,c,
<br /> �, TOTAL SQUARE FOOTAGE: 4, �,-
<br /> , ii ® ^,
<br /> 2ND FLOOR: 3RD FLOOR: ,
<br /> x
<br /> t s as n
<br /> �1
<br /> ESTIMATED CONSTRUCTION COST: f "
<br /> ♦ —. —. —► — . -+
<br /> (Please round to nearest dollar) �§ , yt.
<br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Ni Yes ❑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? IYesd- DPI No
<br /> APPLICATION MUST BE SIGNED
<br /> 545-112(4/09)
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