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ZONING PERMIT APPLICATION ww. <br /> wcountyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> a 04 ❑ Zoning Status;CUP; <br /> —OWNER ADDRESS (Number,Street,City,S1)State,Zip) Deed Restriction;CSM <br /> Z7L5 Viid&Ue/J / A • 5 ulo f eoe(e ,kid": f5; z10 Variance(# <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> e —, t . f•: — • `t� ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> LIE. ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> /)'lE <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/) ID Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL A_I (a. frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 1/4: 1/41/x: ❑ Driveway permits <br /> 157Z�' (state,county,town) <br /> ADDRESS: <br /> Z?15 V I 6 U,el0 Yec9.■ v LAO P2 at Y f tk1 6-35170 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: <br /> a s <br /> 5 eACI h 0 e i i <br /> . 0'this project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. k sx <br /> SANITARY SERVICE: PERMIT NUMBER: °3I <br /> ❑SEWER SEPTIC " <br /> HEIGHT IN FEET: 10. `/j}� NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: � � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) " <br /> BASEMENT: 1ST FLOOR: g A � rip <br /> 4 , , 14 +, TOTAL SQUARE FOOTAGE: 4d <br /> 2ND FLOOR: 3RD FLOOR: i n z- <br /> , <br /> � <br /> �� <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) "� $ 50 600 — __, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Q'ITo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes Q'1T LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ales ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 213o <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (Ie ve blank if none) <br /> 6. Is a location survey required? (see reverse) LYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> CAUT BE <br /> (Continue APPLI on TION Back)MS -►SIGNED-► <br /> 545-112(4/08) <br />