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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 /> I('I` IS ) 3o)Dc Zoning Status;CUP; <br /> OWNER ADDRESS (Nbmber,Street,City,State,Zip) Deed Restriction;CSM <br /> j�Z3) NJc:6e 6; _,.. .1 ?,',, , (te (.-,, SSC`)0 Var. nce(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME ff ,�,/ <br /> M f C kc1e ( .At,, I L Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDR SS f well/septic <br /> C-4 c( f;:ADDRESS l.-) - <br /> (City,State,Zip) (Ci State,Zip) _ CJ S backs <br /> PHONE PHONE` `� e �' Site Plan approval from <br /> (4%C%/ 333 Z;`'-r 7 a..licabletownship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> Iii Fl r plans to scale <br /> V1±1 zC e , - NGLw}rt.-eV-1 <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) -Elevation PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: on oproperty <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER (- 1 Ll WIC )Si -6152--Z` A-- • 60 CZ <br /> TOWNSHIP: SECTION: <br /> � E 1/4: %1/4; Driveway permits <br /> (state,county,town) <br /> ADDRESS: l n <br /> 15-2- 1 2, �►c, (e T• �„_ry Q Cc„t r I (f' ` 3 3 s-c k% 44Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> V Col Pf Jci t !. ' t'.1 0 <br /> PROPOSED PROJECT INFORMATION , <br /> PROJECT DESCRIPTION: ' = e - �1 <br /> . Et This project is a new building or structure. > <br /> El This project is an addition/alteration to an existing building or structure. ` {, ' -,` <br /> SANITARY SERVICE: PERMIT NUMBER: a a - " <br /> ❑SEWER ❑SEPTIC `- ° a ' <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) A , <br /> _ ® - ) � ro: ra. <br /> AREA TO NEAREST SQUARE FOOT: - - rAtt <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ii <br /> BASEMENT: 1ST FLOOR: <br /> TOTAL SQUARE FOOTAGE: 1 i' ;. ai t,;( <br /> ..c�'91 a -. -? <br /> 2ND FLOOR: 3RD FLOOR: .r -'- <br /> E <br /> ESTIMATED CONSTRUCTION COST: iii it, . :° , <br /> (Please round to nearest dollar) "■ --0. "+ -+ $ .-4.--v <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 10No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 0 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? LB yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes LI 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 QNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes LLNo <br /> APIAIUST GED <br /> (Continue PL CT on ON BacMk) BE—►S—*I N—o <br /> 545-112(aoe) <br />