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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 /> C__ <br /> _►^ l'-'3 �w,,�� Wing Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3)-2,- / S',/"ry s i i- _ Variance(# ) <br /> HOME PHONE CEL4 PHONE E-MAIL ADDRESS <br /> 3S, Sit an drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑ Site Ian i uding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of ell ptic <br /> (City,State,Zip) (City,State,Zip— ,H=1,)::::7 <br /> PHONE PHONE _� an approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> F r pla to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elev on of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> EIPARCEL <br /> NUMBER c?G1 i 1 `3 SS�°I S frontage drawn to scale. <br /> TOWNSHIP: SECTION: <br /> '/4: '/4'/4: ❑ Dr wa permits <br /> ADDRESS: (state unty,town) <br /> CSM: 3/. 1.- I 51 LOT 5 1 c - SUBDIVISION BLOCK/LOT ❑ San. ermits <br /> GI Fee (pu ' , rivate) <br /> PROPOSED PROJECT INFORMATION fr l� STAFF REVIEW <br /> PROJECT DESCRI ON: CriC1 <br /> 1 pThc oo;r[j c c,t 9f nun District <br /> . ❑This project is a new building or structure. p i Use? <br /> TThis project is an addition/alteration to an existing building or structure. <br /> SAN ARY SERVICE: 'PERMIT NUMBER: ral Address <br /> NEWER [EPTIC (ne�� =xfi <br /> HEIGHT IN FEET: NUMBER OF STO-IES: (Not including basement) <br /> I-� /rW- ...plain/ <br /> <.a. eland - ch ent) <br /> AREA TO NEAREST SQUARE FOOT: ' <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) © ;;,,��,,// <br /> ❑' ion ,.ntrol permit"'"'.� <br /> BASEMENT: 1ST FLOOR: <br /> Sj TOTAL SQUARE FOOTAGE: ,l (slop'' disturbance <br /> •2ND FLOOR: 3RD FLOOR: I - c 5 fl •/a SS) <br /> ❑ Review ' n Survey <br /> ESTIMATED CONSTRUCTION COST: -10. ♦ ♦ ♦ ♦ and av , options. <br /> (Please round to nearest dollar) y31: <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Efres ENo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eyes ENo EDon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? Efres ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Efres ONo <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) Efres ENo ❑Don't know <br /> 7. Is this to correct a violation? fYes ENo <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) ■ ■ -i <br /> 545-112(4/08) <br />