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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 /> 1 w' t? J z01%/JS.4 Z ' g Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> eed Restriction; CSM <br /> 384toy j /" F Variance(# ) <br /> rHOM PHONE CELL PHONE E-MAIL ADDRESS <br /> ''4 70' 71.Z 1 CIS— 9sa 614f • - , d iuM1 i, ,01AJ 1.Ce„v raven to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> • Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) S C S <br /> PHONE PHONE — ❑Site n ap oval from <br /> applica ownship. <br /> E-MAI L AD D RESS E-MAIL ADDRESS <br /> EIDgorrlans o scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Ion of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ❑PARCEL <br /> rontage drawn to scale. <br /> NUMBER °142G 147"/ Moo / A - 4 r <br /> TOWNSHIP:, I' SECTION: <br /> V t tr ■Ak r �-�-- 4,0 '/4:S %'/4: ❑ Dri -way .ermits <br /> ADDRE / (stat- -.unty,town) <br /> sc� c. 1 7/ 1 ❑ . ' :ry .- mits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> MI (pub'-, .rivate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: (� <br /> / c-IP�!j-� &.,,',/{,el.', Z n District <br /> . <br /> This project is a new building or structure. <br /> vead Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural/Ns•_- s <br /> [)EWER ,IXEPTIC I - (new -xisting) <br /> HEIGHT IN FEET ' �3 NUMBER OF ST RIES:/(Not including basement) <br /> Li We I-td/Floodplain/ <br /> ore an. : chment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) k] <br /> BASEMENT 1ST FL R: rosionControl permit <br /> C1r` 4, TOTAL SQUARE FOOTAGE: l (slopes,disturbance, r <br /> 2ND FLOOR: 3RD FLOOR: �J�� filling/access)i'"A iew Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ .... k... <br /> 1. and available optio s. <br /> (Please round to nearest dollar) r/�C�1 <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? ❑1'es ENo ❑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 2f 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) Ekes No ['Don't know <br /> 7. Is this to correct a violation? ❑Yes -No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ - <br /> 545-112(4/08) <br />