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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 /> Je+t -‘ I..l'i 4 r- (4's-6 <br /> OWNER ADaRESS (Number,Street,City,State,Zip) ❑ Zoning Status;CUP; <br /> fS3/ Dee r t _ Deed Restriction;CSM-)-J �H`QpU(/E Variance(# ) <br /> HOME PHONE CELL PC �r1 �/ E-MAIL ADDRESS <br /> 225 v 6X/ ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRAC V)14 NAME , <br /> D. H. , E•'S )y n ❑ Site Plan including location <br /> ?4 AGENT ADDRESS C��C,.TORA�RE� � e of well/septic <br /> 6e_e r � . <br /> (City,State,Zip) (City,State, ip) t t w�/ ❑ Setbacks <br /> pi 4 d;Soo 14213, 53 70 y <br /> PHONE PHONE ❑ Site Plan approval from <br /> 3 ls- 7500 applicable township: <br /> E-MAIL ADDRESS E-MAIL.AD.RE S <br /> ) O, 6v Li G er/Cr, y eI- ❑ 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 /> PARCEL DvogZ�l/O •9 frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: _,JJ/e 4,... SECTION:i� /[1� 1 ,4: , , : ❑ Driveway permits <br /> ADDRESS: (state,county,town) <br /> 1{53/ Dee/i )--r` ❑ Sanitary permits <br /> CSM: LOT SUBDIVI I N B OCIVLOr (public,private) <br /> 1 ( t'efosse Est,## <br /> PROPOSED PROJECT INFORMATION ' � <br /> PROJECT DESCRIPTION: �7- / `, , , <br /> re 114c P a� _ ,,' <br /> VI This project is a new building or structure. 1 s7, :0> <br /> ❑This project is an addition/alteration to an existing building or structure. , � <br /> SANITARY SERVICE: PERMIT NUMBER: e '_� -1 <br /> ❑SEWER SEPTIC - e a14 '' Y <br /> HEIGHT IN FEET t NUMBER OF STORIES: (Not including basement) <br /> O <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) ° � <br /> BASEMENT: 1ST FLOOR: , $ 3 s r•4, TOTAL SQUARE FOOTAGE: 4, -- <br /> 2ND FLOOR: 3RD FLOOR: 6/10 _ _ <br /> r; r.1.: ,g' ' ' <br /> ESTIMATED CONSTRUCTION COST: �� ; : ,i <br /> $ �A�� <br /> (Please round to nearest dollar) "� "r "� •p , Q�� „ �� .4,-., . 4,..•* � � <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes 1I No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes (,3No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? 'El Yes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? El Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# 4 (leave blank.if none) <br /> 6. Is a location survey required? (see reverse) ❑Yes IN No ❑Don't know <br /> 7. Is this to correct a violation? CI Yes 'I No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ -► <br /> 545-112(4/08) <br />