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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 /> PA-Ci%CtC_ L ALLY <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> g S w y S r Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> grri .q £(9Z LI Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> kpA-"ek s F S( N C s w s-r ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> P.O. 7 c 7 7 . <br /> (City,State,Zip) (City,State,Zip),.. LI Setbacks <br /> pi A.-pt,o.Y to 1 S 3 ?o <br /> PHONE PHONE LI Site Plan approval from <br /> 60/- Z 4 / . 9 o o q" applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> KENO ct dq w..s O r Pi 4 D(Sont. cor^ LI Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: <br /> / CUNT ONiNG: ACREAGE: LI Elevation of property <br /> ❑ NUMBER os i'^ 0 tit./ -c1 Sol- / �-e x frontage drawn to scale. <br /> TOWNSHIP: S TION: <br /> .l.) ,k k t 2 ( .- 0 Li 1/: s '/a'/a: S'A ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> LI Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION - TA t � <br /> PROJECT DESCRIPTION: ) -, <br /> ©N r S TO,2( 4-g 31-c( o pt s � <br /> ❑This project is a new building or structure. - <br /> t-ktis project is an addition/alteration to an existing building or structure. ,- " - r <br /> SANITARY SERVICE: PERMIT NUMBER: °. ° : <br /> ❑SEWER SEPTIC a�� �n� <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) ,-St area <br /> AREA TO NEAREST SQUARE FOOT: fie': <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) "• <br /> BASEMENT: 1ST FLOOR: ' <br /> 3 7,(P + TOTAL SQUARE FOOTAGE: 4 a�®° ml �$ <br /> 4t 4 a - <br /> 2ND FLOOR: 3RD FLOOR: 33 4 <br /> a <br /> ESTIMATED CONSTRUCTION COST: Q� /� i. O.t� ' <br /> (Please round to nearest dollar) --► --► ♦ ♦ ♦ -► $ .�)l /3 Q t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes C11No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes 1No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 21.Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes LYNo <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 ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes LICNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 laioal (Continue on Back) -i -► -► <br />