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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App# <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> 0 ! 4, 0! Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,Ci State,Zip) ((�� t a eed Restriction;CSM <br /> (09.8(p IRviNCrY't� I(z 't( ;tl'tC , �, 53` � Variance(# ) <br /> HOME PHONE�I� CELL PHONE E-MAIL ADDRESS <br /> 5— r <br /> Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION . d includes dimensions <br /> AGENT NAME CON -•CTOR N•• r <br /> M,,,„ ,_■ ,..Utt csvt JR 4.ite Plan including location <br /> AGENT ADDRESS CO r•• TOR ADDRESS o well/septic <br /> Is _ ' _1 :P- `• etbacks <br /> (City,State,Zip) (City,Stat Zip) <br /> PHONE <br /> '' +.41.) <br /> oNE} ,(tc ' .54)5'10 R 'ite Plan approval from <br /> (6c X034,-2.y0 L. =.plicable township: <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 1 loor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ►: Elevation of ro e <br /> PARENT PARCEL NUMBER: CURREN ONIN ACREA P P rty <br /> ❑ PARCEL 3C/a n�-) 3-?6L/Q _ _ ,t frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP• Se5TI : r I It: Drivew <br /> I-�v i - 1/a: I V- '/a'/<: I, permits <br /> ADDRESS: (sta ,County,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanity ermits <br /> (pu private) <br /> PROPOSED PROJECT INFORMATION •PROJECT DESCRIPTION: ,;:t� <br /> - 7 F <br /> / a <br /> . ❑This project is a new building or structure. 1i�; v <br /> This project is an addition/alteration to an existing building or structure. F � . - - ` <br /> SANITARY SERVICE: PERMIT NUMBER: ��+-1",•''W °' � �. <br /> ❑SEWER ❑SEPTIC " ^''a x ` a <br /> ; <br /> HEIGHT IN FEET �- _ NUMBER OF STORIES: (Not including basement) � R * } <br /> AREA TO NEAREST SQUARE FOOT: ;, <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) 59 <br /> BASEMENT: 1ST FLOOR: $e � F;� _ <br /> + TOTAL SQUARE FOOTAGE: , 4 ��1 o A I!ti,' '. <br /> 2ND FLOOR: 3RD FLOOR: 14�, � <br /> ESTIMATED CONSTRUCTION COST: z't r4 ,� .r « °'� e V A <br /> (Please round to nearest dollar) �(� Qpp ,, . 7 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes allo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes lallo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? ❑Yes ,tilNo <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 latlo ❑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(4/08) <br />