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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 441 71-- D/( `C Ski di VAL4-1 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Strei,City,State,Zip) / Deed Restriction;CSM <br /> -3713 � RLJ, , Dr, /a , , '_hive ltd/ .�,3 5-Z7 Variance(# ) <br /> HOME PHONE CELL PHONE AIL ADDRESS <br /> 9 <br /> g, "NN97 N Nil ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE T NAME CONTRACTOR NAME <br /> �■: rn- ' r r. ,,Q s . ,I- ❑ Site Plan including location <br /> AGENT ADD'ESS CONTRACTOR ADDRESS of well/septic <br /> $71r L„t.,....,4 br. <br /> (Ci ,State,Zip) (City,State,Zip) �� ❑ Setbacks <br /> v� Pr r/C /-✓7 S3.S9I> A <br /> PHONE PHONE ❑ Site Plan approval from <br /> wy-877 3 II applicable township. <br /> E-MAIL ADDRESS Q E-MA <br /> � IL ADDRESS <br /> - law c.oi „ LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: LI Elevation of property <br /> ❑ NUM ER 07/1-2l1 F 5323-7 R- 1 .(p j f frontage drawn to scale. <br /> TOWNSHIP: //�'� J SECTION: <br /> v i (A,A.e 4,--ev€ ' 3 E 1/a'/: 514/ ❑ Driveway permits <br /> ADDRESS: <br /> �__ J // //--// //Zv / (state,county,town) <br /> 3713 O,J kt.,, �. Zosi 1 ry i€- A.)/ 6-3 S 27 LI Sanitary permits <br /> CSM: LOT Li SUBDIVISION BLOCK/LOT <br /> 3 <br /> ( (public,private) <br /> PROPOSED PROJECT INFORMATION P7 T x li7 <br /> PROJECT DESCRIP N: -' <br /> Litt-IpN: 0 n/ <br /> IgThis project is a new building or structure. ' - <br /> ❑This project is an addition/alteration to an existing building or structure. .: <br /> SANITARY SERVICE: PERMIT NUMBER: •• ' <br /> ❑SEWER ❑SEPTIC e11A <br /> HEIGHT IN FEET: yy NUMBER OF STORIES: (Not including basement) n <br /> /2'S / - :r. e1 °`�:�t ' �s���' <br /> AREA TO NEAREST SQUARE FOOT: -, i- ' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) b <br /> BASEMENT: 1ST FLOOR: IQ • ''' <br /> /QM 6,77-- +,, TOTAL SQUARE FOOTAGE: +' f <br /> 2ND FLOOR: 3RD FLOOR: ,° <br /> Alit N/� 67z- �� -e <br /> ESTIMATED CONSTRUCTION COST: z o <br /> (Please round to nearest dollar) "♦ "'∎ ♦ '♦ "♦ '0- $/J ��O • • ! a <br /> / �.454. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑JYes .No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EiNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Al No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes E1 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) tYes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes KNo <br /> n �` ��— �O APPLICATION MUST BE SIGNED <br /> C/� Q / (Continue on Back) ♦ —► —► <br /> 545112(4/OB) .5-72_-- <br />