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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 /> —,A7-46S R Li - SRS - A A Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> (P 9 29 -D o Nn/y Q /tL t- d, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> g H te- g e =•Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 4'D4t4S Ti e 5 t c N Con S T ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> Po i" 777-7 . <br /> (City,State,Zip) (City,State,Zip) <br /> ill +•D(S0,4 L) ( S 37 01- C*Setbacks <br /> PHONE PHONE ❑ Site P n approval from <br /> 60g- 2 '-t( •40o9 7labletownship.E-MAIL ADDRESS E-MAIL ADDRESS <br /> - 4D40Fili47, o r plans to scale <br /> •PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi n Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P p rty <br /> ❑ PAR <br /> NUMCEL t` � ronta a drawn to scale. <br /> BER 9/O^�,W- $�5p - S -I g <br /> TOWNSHIP: SECTION: C r it Driveway p rmits <br /> k )IN1so2 N- i 1/: .E 1/41/: iv <br /> (state, a town <br /> ADDRESS: ( tY+town) <br /> ' 9 ;i c `Tfvnny g1L., 2aa;D <br /> 11 Sanitary ermits <br /> CSM:- 7 O( S LOT SUBDIVISION BLOCK/LOT (publi ,private) 4/ l <br /> // <br /> PROPOSED PROJECT INFORMATION <br /> T <br /> PROJECT DESCRIPTION ; <br /> I SIDai a/7tTiQf (Nl'Cti ' ?c < . Fki ,-Vt,a B , <br /> i s7x•• ❑This project is a new building or structure. � <br /> calbis project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: - ' <br /> a <br /> ❑SEWER ❑SEPTIC - . a ° <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> / 0 '6 '� / SToda Y ....k, % <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ;0 '_ $� <br /> BASEMENT: 1ST FLOOR: p <br /> 4, TOTAL SQUARE FOOTAGE: + $4 mi c- = <br /> ® a7. - <br /> 2ND FLOOR: 3RD FLOOR: <br /> SR- o� , <br /> ESTIMATED CONSTRUCTION COST: ♦ --► ♦ ♦ ♦ ♦ L 0 ! :A*•t 0 f <br /> (Please round to nearest dollar) $ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ;,No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 2cNo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? N7Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes DSNo <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 IgNo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 11■o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ —► <br /> 545-112(4/08) <br />