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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME I�), <br /> Der^s bie-AQ e r■ .lt Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Set,City,State,Zip) I •eed Restriction;CSM <br /> 33 63 Q t rs'— Rc PAC o,r 1 e,,.-J S3 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> e83�"-70 le :Re Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRE CONT TOR ADDRESS of well/septic <br /> (City,State (City,State,Zip • etbacks <br /> ..._ (... <br /> PHONE PHONE ea 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/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> Li NUMBER QCi Q 1r3`6 i �O ,— I f h s frontage drawn to scale. <br /> TOWNSHIP: . Tj(7N: <br /> 0 r ��-.. ,A: 1/41/4: 3 Driveway permits <br /> state,county,ty,town) <br /> '�^u--9----- Sanitary permits <br /> CSM: G LOT I SUBDIVISION BLOCK/LOT <br /> ublic,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: f <br /> 'this project is a new ilding or structure. ,' z. is .? i . <br /> ❑This project is an addition/alteration to an existing building or structure. - - ,.,1"...3;,": <br /> SANITARY SERVICE: PERM .U 'ER: L f -1 " - , . <br /> ❑SEWER �� PTIC � r� .tr f 'r. <br /> HEIGHT IN FEET: NUMBER OF S •RIE : (Not including basement) s <br /> AREA TO NEAREST SQUARE FOOT: ,,:- <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) .,> a � <br /> 3 <br /> BASEMENT: 1ST FLOOR: •� �� <br /> 4, TOTAL SQUARE FOOTAGE: 4, 7,1 ,, <br /> 2ND FLOOR: 3RD FLOOR: 3:- <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ ♦ --0. ♦ ♦ -► $ 1 ,� a.: ^ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Zilo ❑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 o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ,Yes <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 �Jo ❑Don't know <br /> 7. Is this to correct a violation? CI Yes J'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />