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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 /> O&Grfl &60-77 Sfoi27 TiL e6,4/� JI 2 gA1 eea w Zoning Status;CUP; ■l <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> eed estriction;CSM <br /> �y �c �/ CCri2 0 /�r�e/Il1 wls SAS 9� ce(# 9z80/i' A 2 <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ft <br /> Site Plan drawn to scale ` (V / <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions / <br /> AGENT NAME CONTRACTOR NAME <br /> ,A/ / b A/ t<Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> .fS� lie"�/ZS iez) <br /> (city,State,Zip) (City,State,Zip) Setbacks 63170//0 2 <br /> PHONE PHONE LJ- <br /> G�'�'�02 God ,/ Site Plan approval from ��1 <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS / /� 4,,�(//J�r_/ <br /> OK Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn <br /> PARENT NUMB R: '':yR .- ACREAGE: `I Elevation of property <br /> 0 NUMBER I' f 01_, o s� J frontage drawn to scale. <br /> TOWNSHIP: SECTI '/ <br /> Pi,�e Sir ,�. N ,/,/. /' Driveway permit <br /> 4- <br /> ADDRESS: / (state,coun ar <br /> 8/ 2 r g7/eeek /6 U /ZGA✓.,G GtJ� 3.,9' - Sanita <br /> CSM: 5-6 ii LOT SUBDIVISION BLOCK/LOT <br /> (public, • <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION/:/ / e �' <br /> P) <br /> ❑This project is a new building or structure. �, .v <br /> This project is an addition/alteration to an existing building or structure. r �, - ` .tb <br /> SANITARY SERVICE: PERMIT NUMBER: : ; i4 , <br /> 1:1 SEWER KYSEPTIC ed � � , <br /> - a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � <br /> / '- = . $ 2-4- tt. <br /> AREA TO NEAREST SQUARE FOOT T� .4*1 � <br /> �� ' '' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) // <br /> BASEMENT: 1ST FLOOR: <br /> l �j j TOTAL SQUARE FOOTAGE: , i. d 3 i..- E ' <br /> 2ND FLOOR: 3RD FLOOR: [/0 <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ '/ 7�� , f t a• : It <br /> (Please round to nearest dollar) $ 5/ J <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Ei-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 0 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 54No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(aios) (Continue on Back) —► —► --p <br />