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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME nn <br /> ADAA" l r( le, •p Zoning Status;CUP; <br /> OWNER <br /> (`ADDRESS (Number,Street,City,State,Zip) 5 3 Deed Restriction;CSM <br /> HOME PHONE I- � i CELL PHONE L.o(1L4 -' ( EMAIL AD.-ESS 5 2-3 Variance(# ) <br /> 00 8-64 ?-7(ioo (a-6761-7(100 7(1oo ,- — :_-____------ _ ---__ - r Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION : d includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ASite Plan including location <br /> AGENT ADDRESS CONTRACTO ADDRESS of well/septic <br /> • <br /> (City,State,Zip) (City,State,Zip) i kSetbacks I®, I 6N/ <br /> PHONE PHONE • TA Site P n approval from <br /> ' ap cable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> FA T- - to scale <br /> r. <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P rty <br /> ❑ PARCEL —�1)— )j 1 6/D/ R---.3 ,a.5 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 'De , Q\A ), S '/<: ,/4,/: ►= Driveway permits <br /> ADDRESS: (state,county,town) <br /> 3 & 13 <br /> CSM: LOT SUBDIVISION BLOCK/LO Sanita •ermits <br /> T r^STf 0 0■0 - 'pub• ,private) <br /> PROPOSED PROJECT INFORMATION ; ;' <br /> PR ECT DESCRIPTION: / ) Lit&,^ " i <br /> . ❑This project is a new building or structure. - a-r <br /> This project is an addition/alteration to an existing building or structure. ;W , -- <br /> SANITARY SERVICE: PERMIT NUMBER � _, <br /> ❑SEWER ,.SEPTIC �� <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) V-iii;i6;:ii,'Zi <br /> AREA TO NEAREST SQUARE FOOT: -_ 41,4---'-; :=:°;°''-i <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) k .; � �- - p <br /> BASEMENT:9 1ST FLOOR: _ � `„ <br /> 4, TOTAL SQUARE FOOTAGE: 4, ,;� �1 t gqw Y,_ ,,,,..„ ,,,-,-_2ND FLOOR: :- 3RD FLOOR: ( ( C a i >�0,...,: <br /> ESTIMATED CONSTRUCTION COST: "3:!:t.,0404.0)0,20, :- <br /> (Please round to nearest dollar) -O "'o -o $ �� irav! <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes &lo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes N(No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? tiiiYes ❑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 ',No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► ♦ -► <br /> 545-112(4/08) <br />