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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 /> "r6' ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) -L Deed Restricts n' <br /> Z'' Mmtt a �T `'`^�' ' 7 � Variance(# o , CSM ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> LI o•-_ .rrr� <br /> ,--_:..s...-� - =' cam?) 1=1 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME 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 Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING:(http:// <br /> El accessdane.co.daAllceR.EWAGLEUS/) <br /> ¢ -�,,a� frontage drawn to scale. <br /> NUMBER DSO`s-x.02--$1v"5d'O �� <br /> TOWNSHIP: SECTION: <br /> e�L� t"I '/.: �,i,,/ '/1/. ❑Driveway permits <br /> ADDRESS: °� t (state,county,town) <br /> B 4% k77)015‘476‘ 1�� � 535 2"k <br /> CSM: SUBDIVISI N BLOCK/LOT ❑Sanitary permits <br /> to (public,private) <br /> PROPOSED PROJECT INFORMATION E 5 <br /> PROJECT DESCCRIPTIIONN ' 1 A "f`„,":74,11, E M <br /> This project is a new building or structure. ��� E,E <br /> i �� <br /> ['This project is an addition/alteration to an existing building or structure. ¢ '` s� : . <br /> SANITARY SERVICE: PERMIT NUMBER: ,cy ° <br /> EWER REPTIC l7j—Zak Z. � R3 , <br /> HEIGHT IN FEET: ++ NUMBER OF STORIES: (Not including basement) » <br /> Ya` ` ■ e tg ”: <br /> AREA TO NEAREST SQUARE FOOT: " <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ' <br /> BASEMENT: 1ST FLOOR: <br /> '0,1 � <br /> (0'7)3 `1�� + TOTAL SQUARE FOOTAGE: 4, * �� F <br /> 2ND FLOOR: 3RD FLOOR: @ E ' s E 0. <br /> e r- Survey , <br /> ESTIMATED CONSTRUCTION COST: f 3� $ ' <br /> (Please round to nearest dollar) ♦ ♦ ♦ I"I(3, paw 3 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes ENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ENO ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? JG Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ENo <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 ENo ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes gNo <br /> APPLICATION MUST BE SIGNED <br /> 54e-112(4/08) (Continue on Back) <br />