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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT-to.Web-App# <br /> PROPERTY OWNER INFORMATION,,, ;_ 4:'-','fl.";_ _;'.0 '--;"=,.=,^j.".!---' -.-1;-.-1---1- -'-' CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 1:)4:3-,\-e- .1- az)c)i LA ''.\ ca, %/\6 m"... kg <br /> OWNER ADDRESS (Number,Street,City,State,Zi ) Zoning Status;CUP; <br /> Deed Restriction;CSM <br /> a 3 g 41 VG e n o IA LA.-) � ✓t 1 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS LJ 7 7 <br /> e - `S77 71,,7' 5-6,02 on Site Plan drawn to scale <br /> AGENT INFORMATION. . ,' CONTRACTOR INFORMATION .;,• and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> 0 j YN.e_,r-' s-Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) Et 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:dane.wi.usn . ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: P P Y <br /> ❑ PARCEL BER DS( 1' o 1 I O CIS O /2 I / frontage drawn to scale. <br /> NUMrJ <br /> TOW SHIP: SECTION: ❑ Driveway T '/<: '/<'/4: Y Permits <br /> ADDRESS: Q.0.0 (state,county,town) <br /> 3 g ` ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION I BLOCK/LOT (public,private) <br /> . 6 s IA <br /> ; A PROPOSED PROJECT INFORMATION ti i <br /> PROJECT DESCRIPTION: ei , <br /> 54-0 e his project is a new bu}idfng or structure. , ` <br /> ❑This project is an addition/alteration to an existing building or structure. : ,_ r ,1;. .. . <br /> SANITARY SERVICE: PERMIT NUMBER: 4214 6:724001 ' 1: <br /> ❑SEWER ❑SEPTIC � � a <br /> HEIGHT IN FEET: / NUMBER OF STORIES: (Not including basement) s , <br /> AREA TO NEAREST SQUARE FOOT: ® 0# - � <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) # : <br /> BASEMENT: 1ST FLOOR: �, � <br /> ,, TOTAL SQUARE FOOTAGE: ,j, � � of •. t• g <br /> 2ND FLOOR: 3RD FLOOR: / ,qi!„ . - Y <br /> 9 . <br /> p <br /> ESTIMATED CONSTRUCTION COST: Q� <br /> (Please round to nearest dollar) "� "� 'P L1 0 0 di' 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes Iallo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ®.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? t®-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 E.No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes 'io <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —0. -0. -0. <br />