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:ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUST MER TO PROVIDE <br /> (21nER NAME <br /> • h'laS d lbdhnrz Aiic er] oning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) '- / Deed Restriction;CSM <br /> 5'a7 bakrvt-e,, 1r �/ i naLee k I -S35g7 Variance(# ) <br /> H E PHONE CELL PHONE E-MAIL ADDRESS <br /> X310 c;279'a78 7 00.ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME i CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Setbacks <br /> PHONE PHONE ❑ Site P : -pert val from <br /> appli :ble :w,ship. <br /> E-MAIL ADDRESS E-MAIL /12Kloor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: property <br /> ❑ PARCEL 1 .-- <br /> frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> S©r','�` .e I( '/4 : '/4'/: ❑ -Driv- n-nits <br /> AD RESS: (st-& ,ty,town) <br /> 56 2- 7 Ak-y.Pn 1 r 0-44.nc,ke I✓I 6i35 7 ❑ Sa . • permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (p •lic, • 'vate) <br /> PROPOSED PROJECT INFORMATION 7"_ <br /> PROJECT DESCRIPTION: <br /> —� F.T/»i 11 Roar: /9d�,�. » . F. <br /> . ❑This project is a new building or structure. ,,,Y4::,3-44 <br /> his project is an addition/alteration to an existing building or structure. a <br /> SANITARY SERVICE: PERMIT NUMBER: <br /> f <br /> ❑SEWER SEPTIC A w - <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) , <br /> e - tt• mk <br /> c. ft.REA TO NEAREST SQUARE FOOT: '' i <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ®� ® � <br /> CamwZ s��9ce top j TOTAL SQUARE FOOTAGE: , � - � = <br /> 2ND FLOOR: 3RD FLOOR: �� : ' s "4 <br /> t� 4 -. <br /> u' <br /> m �` <br /> ESTIMATED CONSTRUCTION COST: --► --► ♦ --► ♦ ♦ cry - <br /> (Please round to nearest dollar) 30 D Ci , a • - „► . e <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes :f No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes (ENO Li 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? ❑Yes M 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 ®No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Xi No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(a/os) (Continue on Back) -i —I. -* <br />