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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web•App# <br /> PROPERTY OWNER INFORMATION` CUSTOMER TO PROVIDE <br /> OVXN R NAME / <br /> nrrAtrn 0`14 tCf o n Zoning Status;CUP; <br /> OW DRES�s (Number,sce City,sc e,zi ) J� Deed Restriction;CSM <br /> -� LS Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> - 40--q a. -) ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0!4 Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (Cu,State,Zip) (City,State,Zip) "i 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: CUR NTZO ING: ACREAGE: ❑ Elevation of property <br /> ❑ NUM ER OC1/0°6 1615°CS -le x �T 0 frontage drawn to scale. <br /> TOWNSHIP: SEC__TIbbON: <br /> j <br /> Vi' vvAsor G 1/4. N %1/ <br /> g- .5,= � Driveway permits <br /> state,county,town)I R.5) ( `� ) <br /> //17 Y°` °`�O� Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION ""°° <br /> PROJECT DESCRIPTION: <br /> '�er. r sl.o 111 <br /> This project is a new building or structure. X ''4} :4'wi .. <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: '® ° - �- ' <br /> ❑SEWER SEPTIC , i ! s 1 <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ', `,' <br /> 11 ri:OROT: *` fi . a- , . <br /> AREA TO NEAREST SQUARE FOOT: , , <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) rv` '� �'- <br /> BASEMENT: 1STFLpOR: �k ��' ) ' ; <br /> • ,, TOTAL SQUARE FOOTAGE: ,j x, �nt", <br /> is �� <br /> 2ND FLOOR: 3RD FLOOR: . <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) --► � -0. -0. $ � �� - s <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 'W No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes EtNo ❑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? -4a 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 iitNo ❑Don't know <br /> 7. Is this to correct a violation? ., Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -0 <br /> 545.112(4/08) <br />