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II <br /> .ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NA <br /> 1lht-n-N 14-1 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Striet, PJ City,State,Zip) /1 Deed Restriction;CSM <br /> 60(,O 3 Cke.�DO>P�A-IQ- � U112' Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> • 8 '0 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME \ CONTRACTOR NAME <br /> 1\ ‘Arl , — v—' — <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> /1 1 i r-'‘ nib INNe5a-1 +ems, . <br /> (City,State,Zip)SV i.-t tp,e_p,A le-/� W I (City,State,Zip) ❑ Setbacks <br /> I S 25'9 0 <br /> PHONE PHONE — LI Site Plan approval from <br /> (,,p$• $g41-, 4-33 i applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> leb 4 a--+s-row 1/4: <br /> ,/,/4. ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 64,0 3 C' a- C-141-- Oz. ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ° 7'- <br /> PROJECT DESCRIPTION: - - 4 ." f <br /> ❑This project is a new building or structure. <br /> ,This project is an addition/alteration to an existing building or structure. ._ <br /> SANITARY SERVICE: PERMIT NUMBER: ° "s <br /> ❑SEWER SEPTIC � tI 4 *. , .,' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> g� <br /> AREA TO NEAREST SQUARE FOOT: - F-`' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ,, < <br /> BASEMENT: 1ST FLOOR: ®a ' <br /> S.c3c 4, TOTAL SQUARE FOOTAGE: 4, + - - <br /> : E s s <br /> 2ND FLOOR: 3RD FLOOR: <br /> r j <br /> _ $ eye .: <br /> ESTIMATED CONSTRUCTION COST: $ _ <br /> (Please round to nearest dollar) —. —. -. -. -. -. $ �g j <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes L;avvo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 4 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Wes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? '0,Yes LI 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 'Jo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 1lo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />