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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ."-S0\"."..‘."-S0\"."..‘ am L" (1 V kV-. ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) .� r Deed Restriction;CSM <br /> `'SO \ �,,v, �r�,\ V,A..c,..h mil. C3 9i ') Variance(# ) <br /> HOME PHONE CEA PHONE E-MAIL ADDRESS <br /> L.Uoab')335-2517 ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME r CONTRACTOR NAME <br /> N-�q� �-eL. . -, ❑ Site Plan including location <br /> AGENT ADDRESS `_ p CONTRACTOR ADDRESS of well/septic <br /> w'32.- 46 �o.Ccon L.k2A 12/), • <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> Nit -v ,A•tt w l 17 Zi 6vci <br /> PHONE PHONE ❑ Site Plan approval from <br /> ,t tU'b `A.- 4 - 0)% applicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.t3ane.wi.us/ <br /> PARENT PARCEL NUMBER: CURRENT NING:/ ACREAGE: ❑ Elevation of property <br /> ❑ <br /> NUMBER <br /> OSW` - 8301 1 I . frontage drawn to scale. <br /> TOWNSHIP:n a SEC ON: \r(/� U Driveway permits <br /> 14: 3.- ' -1/4-1/4: <br /> ADDRESS: �f�� N (state,county,town) <br /> 1�C) I a 111 e ❑ Sanitary permits <br /> CSM: LOT V SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION 7 y !': T-f <br /> PROJECT DESCRIPTION: nn ; <br /> • <br /> . ❑This project is a new building ,r structures g <br /> *This project is an addition/alteration to an existing building or structure. ' ., ,1 <br /> SANITARY SERVICE: PERMIT NUMBER: . 1 e a �` 7, <br /> ❑SEWER ISpEPTIC : a e a .Y t�' <br /> HEIGHT IN FEET 1 NUMBER OF STORIES: (Not including basement) <br /> '.:..c., ice v�k , .. ` a°r y,. <br /> AREA TO NEAREST SQUARE FOOT: -7� ® <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 4� � -4 -� <br /> BASEMENT: 1ST FLOOR: <br /> V. <br /> t M <br /> R t4 a)j, TOTAL SQUARE FOOTAGE: j .,4'rt a <br /> 2ND FLOOR: 3RD FLOOR: <br /> t <br /> ESTIMATED CONSTRUCTION COST: �` - ' <br /> (Please dollar) ♦ ♦ ♦ ♦ ♦ ♦ $ �5t1,0� z .' o. r-a® <br /> Please round to nearest dollar k ! p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? CI Yes No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes LI 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 /> I O �� (Continue on Back) —► —► <br /> 545-112(4/08) <br />