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ZONING PERMIT APPLICATION www.countyofdane.com UPPLEMENT to Web�App# <br /> r <br /> PROPERTY OWNER INFORMATION ,a;;; _ ,T`iv, + i:1? �^ „ , <br /> OWNER NAME °' i3 "" "` CUSTOMER TO PROV E <br /> D� 4- a °-_� Zoning Status;CUP; 1 <br /> OWNER ADDRESS (Number,Street,Ci y.State,Zip) <br /> eed Restriction;CSM <br /> a3 L Street, <br /> rY1dv1 f�� Variance(# ) -3 <br /> HOME PHONE / CELL PHONE E-MAIL ADDRESS <br /> 5 1. ~5-6D Z Site Plan drawn to scale <br /> AGENT INFORMATION._. CONTRACTOR.:INFORMATION , , and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> L4/c N..1 r+5 0 >n <br /> 't'' -o Site ' '� ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS f <br /> Jra, - e <br /> (City,State,Zip) (City,State,Zip) A Setbacks <br /> PHONE PHONE `Site Plan approval fronkl k <br /> pplicable township. <br /> .P <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> XFloor 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 y <br /> ❑ PARCEL S 421 / frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: / <br /> Du N k t 1/4: %IA: Driveway permi <br /> 2 �j state,county own <br /> 3 O G/ , /' � -t� `r ) <br /> ADDRESS:02 <br /> !(//����� Sanitary p_-�.• 's iv/A_ <br /> CSM: LOT SUBDIVISION BLOCK/LOT public, . <br /> PROPOSED PROJECT INFORMATION ',. " - : : ,',''1''''tj 'TA ..V.7:, <br /> ; <br /> , a' <br /> PROJECT DESCRIPTION: r asT <br /> +.nGY 4 'P ,' <br /> sfP 4(/) . �� � � , <br /> ❑This project is a new building or structure. „ Ll L <br /> This project is an addition/alteration to an existing building or structure. -,- ''', � 0 <br /> SANITARY SERVICE: PERMIT NUMBER: � E�1�e-,:s1.-':=C' ' <br /> t <br /> ❑SEWER C ,SEPTIC -''',:',-,1,,,..„':,- ': c-- <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: - b. 2,�, t 5 <br /> (Outside dimensions including unfinished area attached garages and above grade decks or porches) ',. `""` z " <br /> BASEMENT 1ST FLOOR: ; <br /> e 6 ag <br /> r4 W / L��C� / L/ 4 ,1' TOTAL SQUARE FOOTAGE: 4, 9 . . 'j <br /> 2ND FLOOR: 3RD FLOOR: �'+�=�0� . ; l /{ v <br /> i c r�5 1 <br /> ESTIMATED CONSTRUCTION COST: QQ�� $ /., , � <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 -1 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? LI Yes A o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes 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) ❑Yes t o ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes I No <br /> APPLICATIUST B—E S—ID <br /> (Continue on ON BacMk) ► ►GNE <br /> 545112(4/09) <br />