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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE,g NAME <br /> (/ {"t ❑ Zoning St ;CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zip) D estriction;CSM <br /> 012114 51&i--,;.,,/lC /'<" Z--; '-/-0,-7 (.2 -- 5- x ariance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> /� g/-7, '/So- -. s - aa,ce, Site Ian drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION an includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ( ‘.'t•—/" L ./3as-", it Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS o well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE I❑ S pproval from <br /> iP cable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F or plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE , P P rty <br /> D PARCEL O 057 -3y"�_f ' t „ ,� �0 frontage drawn to sc- <br /> NUMBER <br /> TOWNSHIP: SECT N: .���-- 1 <br /> �cy-,,t(�4 � .1/4. ,...s L-_, ' oh..S Vu ❑ Dri •-y permits <br /> s te,county,town) <br /> ADD ESS: <br /> • g95- 5,� ,�SU 7(�- '( ' Sanitary permits <br /> C M: LOT SUBDIVISION BLOCIVLOT (public,private) <br /> . PROPOSED PROJECT INFORMATION v <br /> PROJECT DESCRIPTION: �� <br /> C 4g � <br /> I <br /> • ❑This project is a new building or structure. - fl �� <br /> 8 This project is an addition/alteration to an existing building or structure. a 4 <br /> SANITARY SERVICE: PERMIT MBER: 1 � 1 i a �r "' -� <br /> ee Fn�a I Fro ►vt �' -. z <br /> ❑SEWER SEPTIC d � � -, <br /> HEIGHTAFEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: `` x �, Ka <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) r „ ` <br /> BASEM�f� 1STFIO,O 1 <br /> /" � t�' /� + TOTAL SQUARE FOOTAGE: j al '.Yz+!v, , <br /> 2ND FLOOR: 3RD FLOOR: H) <br /> ,:'" - - <br /> ESTIMATED CONSTRUCTION COST: � "° r � e <br /> (Please round to nearest dollar) -0. P / � Q�� ;, <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes enlo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes a No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? eYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes callo <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) DYes EtNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes callo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -* -► -► <br /> 545.112(4/08) <br />