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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 /> cT/1,sreJ ScNi iVT. (11- 741001.4r 6vt c/c <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> 176►8 L.rc,v LN�vE Deed Restriction;CSM <br /> �EF Rr/r LD Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> *if-44Y/3 7JL-3 $ J-e4afij-c.s Q Yrn4ad,('grl,L ❑ 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.dane.wi.usn <br /> PARENT PARCEL NUMBER: D / � CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL 2,413`80 I 124 I <br /> NUMBER rJ7��' `' y�v frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> &Ort'746-6 617-426" ,Z 1/: .74v 1/1/: <no ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 170 1-6-0 AI `4sA s A -,-,7e60 .57, '3/ ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 447y'Y Z (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: I - 4'!-E'it ' <br /> REDO F-+1NO1 1%0A)/ MP 60.4Ptt;►E E' 15449 4 #'-L1Eu , I -: t :-'7 <br /> ,471; <br /> z- , <br /> • ❑This project is a new building or structure. ,� �, �„�� � , <br /> 521 is project is an addition/alteration to an existing building or structure. <br /> ' , <br /> j � e SANITARY SERVICE: PERMIT NUMBER: t� a <br /> ' <br /> a. ,❑SEWER ag PTIC 29Jd 7 FL( ?a V� <br /> HEIGHT IN FEET: <br /> ,� NUMBER OF STORIES: (Not including basement) � ,, ,; � �� ��'�'`�"� <br /> x a (- g r a a <br /> AREA TO NEAREST SQUARE FOOT: , ;�, ,' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ', <br /> BASEMENT: 1ST FLOOR: a <br /> /2 9v j, TOTAL SQUARE FOOTAGE: 4, e ai <br /> 2ND FLOOR: 3RD FLOOR: <br /> e aka e ,,- <br /> s <br /> ESTIMATED CONSTRUCTION COST: --► �� e <br /> (Please round to nearest dollar) $ a d �. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? krYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property?....,-3.t- 00 - 1 9 ? ❑Yes do ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'?.... des LI ND <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes I1 'I o <br /> . s this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a cation survey required? (see reverse) C1Yes ❑No ❑Don't know <br /> 7. Is this correct a violation? ❑Yes �o <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —i► —► <br /> ( ) <br />