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y • <br /> a <br /> 1 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 11011/4) + 1-041/4A Vt Sc i it d c11 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (N mber,Street ty,State, ) Deed Restriction;CSM <br /> 1220 (Ni <br /> wi n CJ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS J <br /> 668- (=.1—S1-3L Z(5 • 1 I 0n3 ..cxh., Icy A. S;v4(o# (air"' ❑ 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: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> NUM ER 62i /61-17-Zo2 Y o-3 ALI I �ti 2 2,0/ frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> 6 Deer .c∎e (c ;70 •/4: 1/1/4. ❑ Driveway permits <br /> ADDRESS: � (state,county,town) <br /> r <br /> 1 LZd A f 1\ C"� ❑ Sanitary permits <br /> CSM: LOT ii SUBDIVISION BLOCK/LOT <br /> Loff-014 • (public,private) <br /> • • • . ' • ; • T NF•RMATION ; t Q <br /> PROJECT DESCRIPTION: *3. fi ' -c k� <br /> R F <br /> ,n 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: <br /> e o ':-::. l* , <br /> ❑SEWER SEPTIC W <br /> e ° a a t � <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> - N ti Q fig'"g!R't3-� '` <br /> AREA TO NEAREST SQUARE FOOT: i. '" � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches). ,4 <br /> BASEMENT: 1ST FLOOR: '® • <br /> 1, TOTAL SQUARE FOOTAGE: , . •' 5,....' ,. <br /> x vi - <br /> 2ND FLOOR: 3RD FLOOR: 4 1]tI <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) 0 -► -9 -∎ $ .3-/co•oc 4 X - • ••,S• <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 1 ❑Yes Ballo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? to ❑Yes digiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement?.... 1Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CJ Yes 1' No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> dd <br /> 6. Is a location survey required? (see reverse) ❑Yes No ' on't know <br /> 7. Is this to correct a violation? ❑Yes p.No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -9 <br /> 545-112(4/09) <br />