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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW NA E 1 (i}i(„ Ero I l,,I c ct\-A `a Lo-hnc I"IUiIv ❑ Zoning Status;CUP; <br /> OWNS DRESS umb r,Sir et,City, ate,zip) Deed Restriction;CSM <br /> A �� ( el f-o t1 COI 6 v 3 ' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> lL.,D'S-M-0q11 ‘.1 - [In- b133 r g rlin/06.66 q,Mi'cr. hei ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ■e II-Y ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) LI 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 UMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> Di PARCEL fronts a drawn to scale. <br /> NUMBER t)0 � G5 i �-0�5��-3111-9 R•� g <br /> TOWNSHIP: SECTION: <br /> -1( 6 AIblb n .1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> cZ.L. 0'' ' , tol 5'65 3d- ❑ Sanitary permits <br /> CSM: LOST SUBDIVI ION BLOCK/LOT <br /> V)—I 1 N` 1071 A„_k-k te (public,private) <br /> PROJECT DESCRIPTION: ' <br /> 9100 d ces4YQL6-11) i , F <br /> . ❑This project is a new building or structure. . i- >, 2 <br /> This project is an addition/alteration to an existing building or structure. - <br /> SANITARY SERVICE: PERMIT NUMBER: °° <br /> Pi EWER ❑SEPTIC : ' " <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) --, ' <br /> €1Us - X <br /> AREA TO NEAREST SQUARE FOOT: -' ,-: -, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) � ., =" e ' <br /> BASEMENT: 1ST FLOOR: `� � ' .. <br /> 0 0 4, TOTAL SQUARE FOOTAGE: 4, , •`��I a r..., <br /> 2ND FLOOR: 3RD FLOOR: <br /> g - ) <br /> L �, ', w M" sYR-a 44 <br /> ESTIMATED CONSTRUCTION COST: l; , <br /> —► -0. —► —► ♦ —► <br /> (Please round to nearest dollar) $ 3? 00 � � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑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? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► <br /> 5455-112(4/08) <br />