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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER.NAME (")(e /A <br /> >o h Z/( P, _ being Status;CUP; <br /> OWNE DRESS umber Street,City,State, Deed Restriction;CSM <br /> Z5 S7 .&, 3iv- r-a° Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 7'-( i 3 Ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> /4 L1f <br /> S4e S(/r/ei)i erlf , d Prl` SCA-V14L Site Plan including location <br /> AGENT RESS CONTRACTOR ADDRESS of well/septic <br /> (City State,Zip) (City,State,Zip) `ik° tbacks <br /> PHONE PHONE Ain;Plan approval from <br /> /F Q , . c- Z • a)c/c, applicable township. <br /> E-RiAIL ADDRESS E-MAIL ADDRESS <br /> ( )Cry u I e' , P . c t rc� Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.us/) levation of property <br /> PARENT PARCEL NUMBER: CURRENT ZON G: ACREAGE: P P rty <br /> ❑ PARCEL / f f /9+�,�, , a frontage drawn to scale. <br /> NUMBER t/( /d I/C^ �7/ b!7(`'v 1 <br /> TOWNSHIP: SECTION: / p 4, <br /> Iii,eGLSea, Y /)C-( 147S S _ '/<: lV� '/a'/4:_ !' i� II .TVewaypty,to <br /> A RESS: ! date,county,town) <br /> ZSCS (Rr, y? r1P e a- (CI a�nitary permits <br /> CSM: L T 0 +� Dlvlsiory `II �„/��BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION ` , - - <br /> PROJECT DESCRIPTION: •� r - Z �,�,� 4 <br /> . ❑This project is a new building or structure. <br /> ❑This project is an addition/alteration to an existing building or structure. , <br /> SANITARY SERVICE: PERMIT NUMBER: r r44sl of a 5'' <br /> ❑SEWER iikaEPTIC ,„ ff a } . <br /> � . <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) � � � R; ,e�._ � ��: <br /> /Z ,v F 1 1 1 1 4 ,° if�'�r sip( �` <br /> AREA TO NEAREST SQUARE FOOT: � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) =' .`3,27 BASEMENT: 1ST FLOOR: , -® 5 <br /> ,, TOTAL SQUARE FOOTAGE: �. ° d it. L�" <br /> 2ND FLOOR: 3RD FLOOR: c <br /> ESTIMATED CONSTRUCTION COST: <br /> -. = o .- x <br /> (Please round to nearest dollar) -5* -► -4. -► -+ -� $ " 1 0Q� � -� ..# .„ <br /> „ <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? LI Yes ,'No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes 8610 ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement'? ❑Yes aFiNo <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) ❑Yes (k2 No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes Oho <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -11. -i. -► <br />