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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME /� ,/ <br /> J v& o 4! 11- �"(lke,.+ ,Pf ❑ Zoning Status;CUP; <br /> OWNER ADD ESS (Number,Stre City, Zip) Restriction;CSM <br /> 114/5,5- C�t�"h� 7e - 7cre I/f 5J 7 Variance(# <br /> HOME PHONE CELL PHONE -MAIL AD RE S <br /> 46.' e3--Yt ❑ 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: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • <br /> '/4'/: ❑ Driveway permits <br /> ADDRESS: <br /> (state,county,town) <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION 1 <br /> PROJECT DESCRIPTION: <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: PERMIT NUMBER: <br /> ❑SEWER SEPTIC r ° a <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / 2 <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 /> y.00 4, TOTAL SQUARE FOOTAGE: 4, ,c * d €,a g r <br /> 2ND FLOOR: 3RD FLOOR: <br /> yon f©� <br /> ESTIMATED CONSTRUCTION COST ' <br /> (Please round to nearest dollar) —0 —0 —∎ $ � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes af No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes I'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? ❑Yes LII 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 />