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jefitn <br /> zP75 <br /> SUPPLEMENT to Web-App# <br /> ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER <br /> � oma s 19.. ERR et) ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zip) <br /> Deed Restriction;CSM <br /> Variance(# <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 CONTRACTOR NAME <br /> ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <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://accessdane.co.diane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: 1 1 CI Driveway permits <br /> �4. �4�4. <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCR TION: , r x g <br /> . ❑This project is a new building or structure. <br /> ,81 This project is an addition/alteration to an existing building or structure. ! <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> ❑SEWER ❑SEPTIC 1 V.1 <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> • it <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimens ons including unfinished area,attached garages and above grade decks or porches) ° `" F <br /> BASEMENT: 1ST FLOOR: s r1 <br /> 3 j TOTAL SQUARE FOOTAGE: j <br /> ‘ .n <br /> 2ND FLOOR: 3RD FLOOR: , <br /> ESTIMATED CONSTRUCTION COST: CC:7 „ ®, <br /> (Please round to nearest dollar) $ /'� 000 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes tEl No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes S No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? El Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes QI 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 2I No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ®No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />