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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME LL/ <br /> C il r fiu �t c,' + er(Sc f 'Z�S/e C ❑ Zoning Status;CUP; <br /> OW R ADDRESS SNumber,,J Street,City,State,Zip)q Deed Restriction;CSM <br /> �5 ///ll cio A/r J�c,� e . 1 �oc?S'f", Wj S3 07 Variance(# ) <br /> O -HONE CELL PHONE E-MAIL ADDRESS <br /> ` •, b - `707,r wq-ces le 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.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: Olevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER 0`7 10 - 19 I - 08`; -I-9 i2 -Z- O..31cv <br /> TOWNSHIP: SECTION: <br /> t....,17--,f: _y,,R 19 1A: WA: ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> LI Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> i � <br /> PROJECT DESCRIPTION: x � s . <br /> - 1251 This project is a new building or structure. ,, ; ,. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: a�� "e a t „ <br /> PERMIT NUMBER: a- ' <br /> 7-4 SEWER /=! EPTIC ,. + 3 , <br /> HEIGHT IN FEET / NUMBER OF STORIES: (Not including basement) �; fi ., <br /> is sawislls3 <br /> AREA TO NEAREST SQUARE FOOT: ® � r a <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 3� "'' :4, <br /> BASEMENT: 1ST FLOOR: -t ® _ r <br /> 4, TOTAL SQUARE FOOTAGE: 1 l t4 -W A3 <br /> x <br /> 2ND FLOOR: 3RD FLOOR: % ' � '. ' - ° <br /> I Lt .,, �; <br /> r eT� sip <br /> ESTIMATED CONSTRUCTION COST: ♦ -► -► ♦ ♦ ♦ .'_'''''''P g <br /> (Please round to nearest dollar) Info, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes El No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes allo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ...- ❑Yes 121 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 A No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -i —► <br /> 545-112(4/08) ) ♦ <br />