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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNS )v/f1i` /2 . /f �,, <br /> /Zip) <br /> ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City State,Zip) Deed Restriction;CSM <br /> 31a'/ Zt�,os !-.4./E , /72cSQ1_, d, c�v- 53-15' variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS I J <br /> 'PI -g3g_760a &08/3g. 1 m/chub CArf a) 2Ci 69,t1 ❑ 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 ❑ 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.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG : ❑ Elevation of property <br /> ❑ NUMBER R I Y00.44 frontage drawn to scale. <br /> TOWNSHIP: SE TION: <br /> epri)9(P (J /E O 1/: AI0 ,/41/: s` ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> c0 <br /> 3/079 C4 he �� '���0 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> : • . • . ' - :0J T NFORMATIO <br /> PROJECT DESCRIPTION: 1 <br /> r <br /> • CI This project is a new building or structure. '.' <br /> 'This project is an addition/alteration to an existing building or structure. t� ,=.. 44- <br /> SANITARY SERVICE: PERMIT NUMBER: ' t n 's =0 � `- , <br /> -`; is.„ <br /> ❑SEWER ❑SEPTIC -3x x <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) �� ° � <br /> c2 ' .1. •• `1A,' ;1= 6 a 1 <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) _' � �; i a' <br /> BASEMENT: 1ST FLOOR: � x � 4 °� ��� <br /> +- yf�eo 4, TOTAL SQUARE FOOTAGE: 4, , s 4• iI ', (M t �� <br /> fit/ • ate' <br /> 2ND FLOOR: 3RD FLOOR: y5a) ,-'..-:' a s°s f15-9 <br /> � � <br /> ESTIMATED CONSTRUCTION COST � � , � • _>••s i �, <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? ❑Yes F-.1 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? NYes ❑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 NiNo ❑Don't know <br /> 7. Is this to correct a violation? CI Yes ,®No <br /> .. :_.37 APPLICATION MUST BE SIGNED <br /> ,-Q (Continue on Back) -► -► -► <br /> 545-112(4/0e) �� <br /> 3g7�ao <br />