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• 131-4(). <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> W)/-LiA/1'1 A/tit2 CC( oning Status;CUP; <br /> OWNER ADDRESS (Number,Street City,State,Zip) eed Restriction;CSM <br /> Li-6G HIGrt Fl etD P.o )At9PLe:Td J r LM , S3 5d2 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADORES <br /> d 6 Q 8l6 0033 4 6 C 1 q t 77-1 )0 1 a te,rCc/q J -645 . 7et <br /> ite Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION nd includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ■ ite Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) AL' Setbacks <br /> PHONE PHONE q Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRE ZONI G: ACREAGE: P P rty <br /> C1 PARCEL a 1V- o7.0g.04 g 2201-c p 3 -Stf ' frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> ti 001.1 TO H 1/4: 1/41/4: ❑ Driveway p mits <br /> c n <br /> state, town <br /> ADDRESS: N IL� � ty�town) <br /> ire s5 th�r-i ❑ Sanita •ermits <br /> CSM: LOT SUB( (VISION BLOCK/LOT <br /> LOT „ 7- \,A;s• PAN ` ` (publ' ,private) <br /> PROPOSED PROJECT INFORMATION .: ,i t -, <br /> PROJECT C PTIO - � , ,, <br /> Vefec ?t� Crarc�'� s,: �C-$sh y <br /> • This project is a new building or structure. ., - � ' <br /> ❑This project is an addition/alteration to an existing building or structure. E f - <br /> SANITARY SERVICE: PERMIT NUMBER: a <br /> ❑SEWER ❑SEPTIC r -`3,m ; <br /> HEIGHT IN FEET: !, NUMBER OF STORIES: (Not including basement) - ° - . <br /> 11 AREA TO NEAREST SQUARE FOOT:(Outside dimensions including unfinished area,attached garages and above grade decks or porches)BASEMENT: 1ST FLOOR: �� ® ; <br /> /12 LI 4, TOTAL SQUARE FOOTAGE: j it �� ” <br /> �� - : <br /> 2ND FLOOR: 3RD FLOOR: h "1w`: <br /> I h <br /> r -,. 4 t - <br /> ESTIMATED CONSTRUCTION COST: //��,�� 1 a `�"`-� 4 T: , � , <br /> (Please round to nearest dollar) $ ,45 )000 , I <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes . lo Cl Don't know <br /> 2. Is there a wetland or floodplain on or near the property? LI Yes 14-No LI Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ,QYes LI No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ii4 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) .83-Yes LI No LI 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(4/05) <br />