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- ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME 7 f <br /> rreca`e r'c/ D�Nya h 5 be-f'TS ❑ Zoning Statu <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> Deed R ction;CSM <br /> c719- Cr in I /4 p e-p G3( 5357,2 • nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> c8-3 2- 52-4 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME •. CONTRACTOR NAME <br /> ❑ ite 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 /> ❑ oor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) evation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAG P p rty <br /> ❑ PARCEL 05C „a „?O 50-0 G - I . 41T frontage drawn to scale. <br /> NUMBER 110 T <br /> TOWNSHIP: N SECTION: . 1 <br /> te f o) 3 'A4: l' W %I : S W ❑ Drive permits <br /> ADDRESS: �/� A e,county,town)tit � <br /> CSM: LOT LOT SUBDIVISION BLOCK/LOT ❑ Sanitary colts <br /> (pub' ,private) <br /> PROPOSED PROJECT INFORMATION N , <br /> PROJECT DESCRIPTION: 1 / __ ., °e �� <br /> 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' o I �� <br /> ❑SEWER & SEPTIC ter:- .1 m 4 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> aka i0.'''a e(a ' 5� <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> sa <br /> BASEMENT: 1ST FLOOR: �Sf <br /> +, TOTAL SQUARE FOOTAGE: j ? P� -1,( 3 <br /> 2ND FLOOR: 3RD FLOOR: �� � � � � <br /> 0 <br /> ESTIMATED CONSTRUCTION COST: ---- � . <br /> "'+ -* -∎ -* - 9 re 4 0 8 S i � <br /> (Please round to nearest dollar) u O <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes o ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes IQ No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ,❑ o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? II Yes LYNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blan if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes o ❑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 />