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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 /> SAM G z SCG ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> V/9/ f'1) Re AD Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 6o$"$39^y3'?Y coS"2 j 9-g 352- SAM TE-,g-.v ! M(s?'• C O n ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> `.4" ca.t SlA)4— ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CUR ENT ZONING: ACREAGE: P P y <br /> ❑ PARCEL O,p O 911—IV e��/�S"T frontage drawn to scale. <br /> NUMBER / ( ��U � � ' y ?1‘ <br /> TOWNSHIP: SECTION: <br /> C6, �^� ��0 !(� '/4: N c ,/,/a: A� Li Driveway permits <br /> ADDRESS: T (state,county,town) <br /> j(4/2� 06 c ROAD, D EE/?F7''-DI W}— C.15-3 1 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> j (public,private) <br /> Q 0 / <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: ,� -, , <br /> DEck. .1n <br /> . ,This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. 4 <br /> SANITARY SERVICE: PERMIT NUMBER: e a - <br /> ❑SEWER SEPTICIIi <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> AREA TO NEAREST SQUARE FOOT: _, : <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) i.- , <br /> BASEMENT: 1ST FLOOR: .. 'S�l.r e e ' <br /> t' 1 Ji 9,4 4, TOTAL SQUARE FOOTAGE: 4, , # = <br /> 2ND FLOOR: 3RD FLOOR: <br /> ESTIMATED CONSTRUCTION COST: a (-erg® °O.€ <br /> (Please round to nearest dollar) ♦ _iii. ♦ "♦ "♦ $ .2,0 0 0 . 0 0 e 41. `` . <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 No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes lki No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? f rYes ❑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 INo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes No <br /> ' ' I APPLICATION MUST BE SIGNED <br /> 545-112(a/os) ��� (Continue on Back) <br /> el , <br />