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. 119 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> !N ' MJ ❑ Zoning Status;CUP; <br /> rOWNERADDRREESS (Number,Street,City,State,Zip) n Gy Deed Restriction;CSM <br /> �S� cS <br /> U� . Sitd3 cum- Na 535 - / Variance(# ) <br /> HOME PPONE CELL PHONE E-MAIL ADDRESS <br /> "_---1 `e'g 53 ❑ 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 /> • <br /> (City,State,Zip) (City,scare,Zip) \ ❑ Setbacks <br /> PHONE , PHONE ❑ Site Plan app roval 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/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ NUMBER O1) 0�5—I 1 I-`�sk�3 — I � d, 1 frontage drawn to scale. <br /> TOWNSHIP' SECTION: <br /> UeIN-e ,/: ,/,/: ❑ Driveway permits <br /> ADDRESS: ' � (state,county,town) <br /> .6 3 tin <br /> ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> 03 0 _ (public,private) <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION:/ 'r <br /> • ❑This project is a new building or structure. : , ifs <br /> phis project is an addition/alteration to an existing building or structure. ,-. <br /> SANITARY SERVICE: PERMIT NUMBER: e s Y <br /> HEIGHT IN FEET: NUMBER OF ST••IES: (Not including basement) „ <br /> ` AREA TO NEAREST SQUARE FOOT: '-�� ® ��� <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 0 `' Z <br /> BASEMENT: 1ST FLOOR: ; e e P ". g - <br /> 4, TOTAL SQUARE FOOTAGE: 4, t� x3� 1,,p° �w <br /> 2ND FLOOR: 3RD FLOOR: <br /> /3e , _„,. _,,,_ , , —,„. <br /> " ids rz 'y <br /> �� <br /> ESTIMATED CONSTRUCTION COST: �0� m e <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ '♦ -T:-:.- r <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? ❑Yes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes Er o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? El Yes ..1294o <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 t110 ❑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 />