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. , C' • <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME r) L <br /> D a',t c) 4/ -, lv -c'1 <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Deed Status;CUP; <br /> 3 1 b G t7( X 1 J w i .5-3 S3 f Variance(#ICtion;CSM ) <br /> .t.r �n <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTO NAME <br /> ,gr-c Ak-.r2 ❑ Site Plan including location <br /> AGENT ADDRESS _..i�,- CONTRACTOR ADDRESS of well/septic <br /> G <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:l/accessdane.co.dane.wi.us1) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT O ING: ACREAGE: P P rty <br /> ❑ NUMBER 0 0(-D 5-/2-29�` S/6 71- -2, 5' frontage drawn to scale. <br /> TOWNSHIP: SECTION: ❑ Driveway I e o i e1 2- ? 1/4: '/.�/: y permits <br /> (state,county, <br /> town). } I , ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> r 92 ° i / <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: � ,h <br /> C� r a it E 0 ,TI t <br /> -ate '4.,k - <br /> ❑This project is a new building or structure. <br /> `= p$ 3 <br /> m This project is an addition/alteration to an existing building or structure. ��• <br /> SANITARY SERVICE: PERMIT NUMBER: e of = g <br /> ❑SEWER 3 SEPTIC � <br /> SETIC � � <br /> HEIGHT IN FEET: w NUMBER OF STORIES: (Not including basement) , : <br /> . - <br /> AREA TO NEAREST SQUARE FOOT: �, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) - �"` ,, <br /> BASEMENT: 1ST FLOOR: n ® 4-l ' <br /> LJ 4, TOTAL SQUARE FOOTAGE: 4, ; 9 td klyi ro <br /> 2ND FLOOR: 3RD FLOOR: / Q ® ® �� axs,; <br /> �. <br /> 1r w 4 Zi.0 si', ' ,...,,,:,v,,,„„,,,..,ry , <br /> ESTIMATED CONSTRUCTION COST: O ,,R j t <br /> (Please round to nearest dollar) "•∎ "•∎ "-■ -I. -+ $ 2. 67-0'6 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Et 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 21 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ♦ -0 <br /> 545-112(4/08) <br />