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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION C STOMER TO PROVIDE <br /> OWNER NAME <br /> Ben am;n D 1<i -) �ic( L Ktt(tcle <br /> .I Zo ing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) D ed Restriction; CSM <br /> cb Tr 'mctn S+• <�re ijar,, W I 5 3 �S riance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> G0a-Li 3b-74bi CcG-y38 7y‘ 1 <br /> 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 pro om <br /> applic e t nship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor tans Cale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Eleva n of property <br /> PARENT PARCEL NUMBER: CUR NTZO ING: ACREAGE: <br /> ❑PARCEL z � front ge dra n to scale. <br /> NUMBER ()S /OJ 1 L tc�jZ'32�i(- J • <br /> TOWNSHIP: SECT nn I� +• , A , <br /> vt� (an 1 '/4: !v `�" '/a'/a: (v ❑Drive y permits <br /> ADDRESS: (st e,coup , own) <br /> g4 ce, Truillcul S+- Sani <br /> CSM: LOT SUBDIVISION OT I: permits <br /> rzthe i_".h+s 84 (p lic,private) <br /> PROPOSED PROJECT INFORMATION TAFP REVIEW <br /> PROJECT DESCRIPTION: <br /> G1nI cvt,A coo p 'g X t c fng District <br /> This project is a new building or structure. 0 Re -e? <br /> Ems project is an addition/ Iteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: '' $ <br /> EWER PTIC (nestle 1 0.0 <br /> HEIGHT IN FEET: / / ( NUMBER OF STORIES: (Not ind/i9 <br /> ing basement) <br /> /ter/ � � a1`15�� p1S11' <br /> AREA TO NEAREST SQUARE FOOT: ( ;{BtfaC�t+ <br /> (Outside dimensions including unfinished area,attach garages and above grade decks or porches) <br /> rosion ;' Dl it <br /> BASEMENT: 1ST FLOOR: <br /> C) 4, TOTAL SQUARE FOOTAGE: , (elopes, ' turbance,gif <br /> 2ND FLOOR: 3RD FLOOR: L/ li 1 <br /> 1 f Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ • ♦ ♦ ♦ 4r enf YSda�lleO�ns <br /> (Please round to nearest dollar) $ l©0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes INNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes PI o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes u • <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank f none) <br /> 6. Is a location survey required? (see reverse) ❑Yes V' o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes W\10 <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► -i <br /> 545-112(4/05) <br />