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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 /> 117k 1( 17IC',f4 ❑ Zoning Status;CUP; <br /> OWNER ADDRESS (Number Street,City, e,Zip) f' Deed Restriction;CSM <br /> ql S/�GGa°i i 7'�t�i x 6/ "-i� (�L, S 355V Variance(# ) <br /> HOME PHONE CELL PHONE , ADDRESS <br /> �S <br /> � 5;11 ` — ❑ Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 01/660/2//10/74 ire ❑ Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> a27 W'///1fi7 57- . <br /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> a/q/19/7/-X35-g?` <br /> PHONE PHONE ❑ Site Plan approval from <br /> dT'_adx. 7s57 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 /> ❑ PARCEL frontage drawn to scale. <br /> NUMBER o61/--3 3Al ,59n- l/ / 3 ' 97 <br /> TOWNSHIP: SECTION:'j 2 <br /> 1�id� Y'9� _3 r 1/4: 1/41/4: AI w ❑ Driveway permits <br /> AD Ss: G�� (state,county,town) <br /> J g s(\ ew to, ❑ Sanitary permits <br /> CSM: V g bl LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION , " : <br /> PROJECT DESCRIPTION: ; - " "r <br /> • ®This project is a new building or structure. ; (i :: a <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: � ,eA°)1 u <br /> =4 t1 J 4� <br /> ❑SEWER ®SEPTIC - o� ; <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) .. --. <br /> 1 � -I � -- <br /> AREA TO NEAREST SQUARE FOOT: -_ ,.::%::,;,!,,,;--- x ar <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: •ab _ <br /> ,, TOTAL SQUARE FOOTAGE: ,+, e �I �a <br /> 2ND FLOOR: 3RD FLOOR: J _ / ,- o- <br /> ESTIMATED CONSTRUCTION COST: $ <br /> (Please round to nearest dollar) k _ - <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 41 No ❑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) ®Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes p No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -► -► <br /> 545-112(4/08) <br />