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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAM <br /> A <br /> � d L <br /> / �/ ❑Zoning Stat P; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restricu M <br /> 3 zz '� p• 3 Variance(# ) <br /> HOME PHONE CELL PHONE,-_ E-MAIL ADpRE SS �n/� „ /��'��re/y a n scale <br /> 23 `� �f3 ■ `_lff/L�L�j/) I/1�.7/�f I\[ (-F�'�n CITa�' <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes t mensions <br /> AGENT NAME C0311 ,Z,TOr NAME <br /> n Site Plan in ding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/s IC <br /> (City,State,Zip) (City,State,Zip) ❑ Setbalys" <br /> PHONE PHONE ❑Site Pla ,=p a-/'•:l from <br /> applicab - • n.hip. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plarv4scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> 111 �(((( <br /> PARCEL frontage���awn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> '/4: ,/,/4: n Drive . r s <br /> ADDRESS: (state',• •\,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑ Sanita p Its <br /> (public, vate) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTQ/ C / � / /co <br /> / 4 ec,. ❑ Zoni istrict <br /> . <br /> This project is a new building or structure. ❑ Per "tt Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 2 00l ^ (new/e ddb <br /> CREWER IEPTIC 'J U (new/e Is In <br /> HEIGHT IN FEET: NUMBER OF STORI S: (Not including basement) <br /> Malt I <br /> rlt CI W I �, lo•dplain/ <br /> AREA TO NEAREST SQUARE FOOT: S o I • (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT � 1STF 1----, Erosio ••41.1 •ermit <br /> i j TOTAL SQUARE FOOTAGE: 4, (slop:t, • •i•ance, <br /> 2ND FLOOR:, 0 0 3RD FLOOR: filling/access) <br /> �/ ❑ Revie - L. on Survey <br /> ESTIMATED CONSTRUCTION COST: -► --► --► _i _i fcy 0,0 _� and .1:i :: e ptions. <br /> (Please round to nearest dollar) I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? EYes No ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? EYes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? Oes nNo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ®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) EYes Tito ❑Don't know <br /> 7. Is this to correct a violation? nYes Al o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —* - -+ <br /> 545-112(4/08) <br /> i <br />