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(11:2b <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS ME S �P <br /> 4 2'A-S "/ ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,CA State,Zip) Deed Restriction;CSM <br /> .11‘‘/ 4_,e57-1 UST £ DA Yi1/,tul533521 . Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 3-5--6720' 2 7/-3o 01 k- ` " 4) i5 A L. - s Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION .nd includes dimensions <br /> AGENT NAME CONTRACTOR ...0,site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) tbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township: <br /> E-MAIL ADDRESS E-MAIL lifFloor plans to scale <br /> PROPERTY/LOCA�TCON INFORMATION (http//accesssddane.co.d A R wi us/) Elevation of property <br /> ® PARCEL �5'D_.3 3 D2O!— �� frontage drawn to scale. <br /> NUMBER D �— pc <br /> TOW HIP: SECTION <br /> �• /� , ❑ Driveway permits <br /> !// t-ANL� �4. 4 4. <br /> - (state,county,town)ADDRESS: <br /> (LC/4),ev71 0i t•D p , / t 1.- A1. <br /> fir/ ( S3So?/ I Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> V65 6 public,private) <br /> PROPOSED PROJECT INFORMATION v f <br /> PROJECT DESCRIPTIO -' <br /> ❑This project is a new building or structure. <br /> This project is an addition/alteration to an existing building or structure. -' , V e�� <br /> SANITARY SERVICE: PERMIT NUMBER: +'R't °° - <br /> ❑SEWER it SEPTIC <br /> .f s <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) . ` <br /> AREA TO NEAREST SQUARE FOOT <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) yi ` 4,"" `� <br /> V <br /> BASEMENT: 1ST FLOOR: s ® ° <br /> TOTAL SQUARE FOOTAGE: 4, � ° xi � °- ' <br /> Ii r _ <br /> 2ND FLOOR: 3RD FLOOR: �� <br /> .., " <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ G� °�_ t,°, , <br /> (Please round to nearest dollar) ��/ �Q ; w <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes -11t 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 fiiNo <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 INo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 2XNo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />