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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OW R NAME <br /> n <br /> W� �� ��� ❑ Zoning Status;CUP; <br /> OWNERADDRESS (Number,Street,City,State,Zip) <br /> PP)- �q <br /> Deed Restriction;CSM <br /> 3()4(1 r V; i ;a1,0 ( 5i- nick- (l C 63C9D Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (./D$-LI44-1171 An r-vn of-i--D Ol I w- c°61 ❑ 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.t3ane.wi.usn <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑ Elevation of property <br /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER C�I0,Z2.°COI- (✓ A-1 0-73 AC <br /> TOWNSHIP: SECTION: <br /> ❑ Driveway permits <br /> BL.5kZKE_ 2 G '/4: NvJ 1/41/4: NE <br /> (state,county,town <br /> ADDRESS: ( t ty� ) <br /> 29 Co Cc,ry5 Esz c.( s-roo+r€5 W ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> l L.Y42acE LU+�S. E....tTpp'-res <br /> PROPOSED PROJECT INFORMATION <br /> PROJECT DESCRIPTION: * :- <br /> �� �� ���,� om` ,- <br /> . ❑This project is a new building or structure. ', <br /> ❑This project is an addition/alteration to an existing building or structure. 4,1 , <br /> SANITARY SERVICE: PERMIT NUMBER: " �:, <br /> • , <br /> ❑SEWER SEPTIC : x . "t% <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) - ;. ' ,. ��� <br /> ■ Le i ' :. <br /> AREA TO NEAREST SQUARE FOOT: ± ®A " 0 <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) "'-` ' <br /> BASEMENT: 1ST FLOOR: $ ® A fr <br /> 4, TOTAL SQUARE FOOTAGE: $e° �3 ' <br /> 2ND FLOOR: 3RD FLOOR: � a " <br /> ILOW:13,0i0i6'7VVO.a, <br /> ESTIMATED CONSTRUCTION COST: ,: <br /> $ s .`sea <br /> (Please round to nearest dollar) "� 25tx'� .vb :4 : <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes 51No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 5:1No ❑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 ❑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) ID Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes IJ,No <br /> 4 crq- 'J APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —10 -0. — . <br />