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• <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to.Web•App# <br /> PROPERTY OWNER INFORMATION . ..;_ , :s;:'„W' ;,,";-; _..L::_: t,;' '',. CUSTOMER TO PROVIDE <br /> OWNER N M <br /> PA .1 ti2-1,(ki r)6 ❑ Zoning Status;CUP; <br /> OWNS DDRESS (Number,Street,City,State, ) <br /> I� C `)i f T3l_►\ t —L Deed Restriction;CSM <br /> l� • l�J l� Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRES <br /> v _ — s I I ❑ Site Plan drawn to scale <br /> AGENT INFORMATION ;': CONTRACTOR'INFORMATION and includes dimensions <br /> ACJT NAME CO.TRACTOR NA <br /> :a' -II Oc s 4 S / j, �,t,?,� , • Li Site Plan including location <br /> AG TA�DESS rn� (_ CONTRACTOR ADDR�SS of well/septic <br /> (C' State,Zip) (city,state,Zip ❑ Setbacks <br /> OW ON LL � <br /> PHONE PHONE ' ❑ Site Plan approval from <br /> �9 (g'S— '1013 �/ applicable township: <br /> E- •ILADDRESS E-MAIL ADDRESS <br /> 4 • ti 1 . ILL I L' Li Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of property <br /> PARENT NiiiiiliMA CURRENT ZONING: p pert <br /> ❑ NUMBER , � fr ontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> /; ❑ Driveway permits <br /> laA(r ac O 1/41/4: <br /> ADD SS: <br /> N (state,county,town) <br /> o (412f)KiA ? Ati ❑ Sanitary permits <br /> CSM: LOA I` SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION fi T E. E L.t' <br /> PROJE DESCRIPTION: t <br /> ❑This project is a new building or structure. <br /> kf <br /> This project is an addition/alteration to an existing building or structure. , 4 4" ' ' <br /> SANITARY SERVICE: m <br /> PERMIT NUMBER: e o <br /> ❑SEWER SEPTIC r3 1 X04 7:!-' te` <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) � �� � <br /> , ie3ra=®igj, s t9 sr , <br /> AREA TO NEAREST SQUARE FOOT: <br /> ®� 1® °. ,4 <br /> . (Outside dimensions including unfinished area,attached garages and above grade decks or porches) eta . <br /> BASEMENT: 1ST FLOOR: `` - 1w � , ,g r® <br /> /. r „7-2,,e tT S-! �, TOTAL SQUARE FOOTAGE: i ,4 aP C v'ts , <br /> OR: ?i stun ' -. <br /> . 2ND FLOOR: 3RD FLOOR: -7 L <br /> ZL( 1 3u i a r�� <br /> �tF8 Cto`7 t „'�', <br /> ESTIMATED CONSTRUCTION COST: <br /> (Please round to nearest dollar) -* -∎ -∎ -∎ -* -0. $ 8� �r ° � <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 ili No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? CI Yes LNo <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) ID Yes Li No IN Don't know <br /> 7. Is this to correct a violation? ❑Yes V No <br /> 4;,; <br />