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. ' <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> O NER NAME _ <br /> 1 �' S �� '� ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) g ' <br /> Z Deed Restriction;CSM S N l'e koCy n t r La Z_,v 3J-3� Variance(# <br /> )HOME PHONE CELL PHONE E- L ADDRESS <br /> / ' O *a5 V� <br /> ( ) S 6k G)4 ` 66'`0 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 5w ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> • <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 /> ❑ PARCEL (5Q'1/ '/ 34' 37P ? R, loa Ica frontage drawn to scale. <br /> NUMBER d` <br /> TOWNSHIP: SECTION: <br /> AID-c,,_ 3 4 1/4. ni 1; 1/41/4. Ar 1A) ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> I 1_5' <br /> tfic f Li/ 0% i L-a� E-4ef«,•1 /A-IT- S 3531 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOC (public,private) <br /> a7 a ,% al H-qd u%p et a <br /> PROPOSED PROJECT INFORMATION , , <br /> PROJECT DESCRIPTION: ,- '-' <br /> 6a` ,' ,a Via^'-:'" Ems` <br /> • Thii project is a new building or structure. a ° <br /> ❑This project is an addition/alteration to an existing building or structure. z- <br /> SANITARY SERVICE: PERMIT NUMBER: A g °a _ tW <br /> . `! f <br /> in SEWER ❑SEPTIC 01:44,C074'41' <br /> HEIGHT IN FE T: NUMBE1 OF STORIES: (Not including basement) <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 /> TOTAL SQUARE FOOTAGE: g" a3 ;.xg° r <br /> ass i i - . <br /> 2ND FLOOR: 3RD FLOOR: l <br /> r <br /> CS/l <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) ♦ -+ '∎ ♦ —0 /(' <br /> 1 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? gYes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ,INo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 4Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes , 1 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) 0Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? LI Yes No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ —► <br /> 545-112(4/08) <br />