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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUST ER TO PROVIDE <br /> OWNER rNAME <br /> A' 14 OWNER ADD ESS (Number,Street,City,State,Zip) oning Status; CUP; <br /> Deed Restriction; CSM <br /> b Lc, £ ' /. i I,/ )t/ TJ c,rl-rii- .: / _a'S_' . ,, Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ` 3 ��/y Ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and i ludes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> y F ( A -- ._, a Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> / 6 (ov ,v T7 i/,-1 yt' . <br /> (City,State,Zip) (City,State,Zip) etbacks <br /> -- /; <br /> PHONE PHONE ' e Plan approval from '74... <br /> appli able township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONI G: ACREAGE: evatlon of property <br /> ❑PARCEL /� frontage drawn to scale. <br /> NUMBER (276-76 7;3o1 7&o/—o j 1 4_( Ii 7q 3 <br /> TOWNSHIP: SECT <br /> C iT / - i /' /. / ,1-3) '/o: /'. '/a'/a: �: w riveway permits Aii_ir <br /> ADDRESS: (state, county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT S ary permits <br /> .) / . ,, �, public, private) P(r\s <br /> PROPOSED PROJECT INFORMATION AFF REVIEW <br /> PROJECT DESCRIPTION• <br /> C9 r,ogi- (:):,,,,7 1— Ga oning District <br /> . ❑This project is a new building or structure. 14‘rnitted Use? . <br /> E This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ral Address <br /> FIEWER r,,I.EP (ne xisting), <br /> HEIGHT IN FEET: ( NUMBER OF STORIES: (Not including basement) <br /> (kVA (-1e,< / °Nl C etland/Floodplain/ <br /> Shore) (attachment) <br /> • " A TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: <br /> rosionControi permit Iv , <br /> / Ss- " ' I5a5 + TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> fillip cc ess) <br /> 2ND FLOOR: 3RD FLOOR: <br /> 5 a S eview Location Survey n <br /> ESTIMATED CONSTRUCTION COST: and available options. <br /> ` <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ b�j , ?JU, p <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes EJNo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes 7a No ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Dees ['No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies i ANo <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) Eyes % o ['Don't know <br /> 7. Is this to correct a violation? Eves glNo <br /> APPLICATION MUST BE SIGNED <br /> 545-112 laios> (Continue on Back) ■ -+ <br />