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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME n��/ <br /> 6() Pi ! ❑ Zoning Status;CUP; <br /> O N R ADDRESS (Number,Street,City.State,Zip) Deed Restriction;CSM <br /> DA y 1� s vobq'r1� k// 5356? Variance(# ) <br /> HOME PHONE CE ONE E-MAIL ADDR/SS <br /> 9 -6G,,f 4 6 ✓n6 L,,�e /,(a ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> LI 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: ACR GE: ❑ Elevation of property <br /> ❑ PARCEL 26/051)-03-1a;0-0 121-? 50x3 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: S TION: <br /> RA Kik �� 1/4: 6 fit ' %1/4: it/ ❑ Driveway permits <br /> ADDRESS: ✓ �� � /"� ! ,�1, /&l�}/�')�/I � 515 y (state,county,town) <br /> CSM: r/`LOT// J �VVSUBDIVISIOONV I BLOCK/LOT ❑ Sanitary permits <br /> 1 I .7 ' n; (public,private) <br /> PROPOSED PROJECT INFORMATION 'I 7 n 7 E "" � <br /> PROJECT DESCRIPTION: ®DD� e a � 6fe � ° <br /> . al This project is a new building or structure. _ a <br /> ❑This project is an addition/alteration to an existing building or structure. + <br /> s -�� ' <br /> SANITARY SERVICE: PERMIT NUMBER: � ,� }�� . � <br /> ❑SEWER SEPTIC i �¢ 41" "''`� yy:;9 <br /> HEIGHT IN FEET: ,/ NUM ER OF STORIES: (Not including basement) � <br /> LI AREA TO NEAREST SQUARE FOOT: <br /> r <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 7 $ s 7 f. <br /> 4, TOTAL SQUARE FOOTAGE: 4, t 'Ol ,1,4 ; <br /> 2ND FLOOR: 3RD FLOOR: ,' ' <br /> 'c 4 m - e <br /> ESTIMATED CONSTRUCTION COST: _ <br /> (Please round to nearest dollar) ♦ ♦ --► ♦ ♦ "♦ $ 1 400 s a i -_ ` <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 21 No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ®Yes ❑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 ❑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 0 No ❑Don't know <br /> 7. Is this to correct a violation? Yes LI No <br /> 3 7- APPLICATION MUST BE SIGNED <br /> 545-112 laoel <br /> (. --- (Continue on Back) —► —► <br /> 91, °° <br />