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ZONING PERMIT APPLICATION www..countyofdane.com 10 <br />. . . • <br />[]No QDon't know <br />CUSTOMER TO PROVIDE <br />• <br />Yes <br />[:]No <br />OWNER NAME <br />[:]No <br />(leave blank if none) <br />QYes <br />QNo QDon't know <br />❑ Zoning Status; CUP; <br />�._ <br />Deed Restriction; CSM <br />OWNER ADDRESS (Number, Street, C , State, Zip) <br />3 (o(, S,, - , e �) - v <br />\,J S`;S <br />Variance (# ) <br />HOME PHONE <br />CELL PHONE <br />MAILADDRESS <br />�] Site Plan drawn to scale <br />and includes dimensions <br />• . <br />AGENT NAME <br />CONTRACTOR NAME <br />Site Plan including location <br />of well/septic <br />AGENT DRESS <br />CONTRACTOR ADDRESS <br />� 2'd <br />❑ Setbacks <br />(City, State, Zip) <br />(City, State, Zip) <br />5,.1 S`35d <br />Site Plan approval from <br />PHONE <br />PHONE <br />C(OQB) 332 2 <br />applicable township. <br />Floor plans to scale <br />E-MAIL ADDRESS <br />E-MAIL ADDRESS <br />vWn t lc¢sn vt coal <br />' ' • ' • ' <br />� - - TMIM <br />Elevation of property <br />PARENT <br />CURRENTZONING: ACREAGE: <br />frontage drawn to scale. <br />1PARCELNUMBER: <br />PARCEL <br />NUMBER Q6\ -2C-A- <br />Driveway permits <br />TOWNSHIP: SECTION: <br />'1�\1,( <br />26 1/4: SIE 1/a1/a: P1\i <br />(state, county, town) <br />ADDRESS: <br />❑ Sanitary permits <br />(public, private) <br />CSM: LOT SUBDIVISION BLOC <br />\ , \ ��O^^T <br />lcJd, 2VA <br />• <br />=;STAFF REVIEW .,,. <br />PROJECT DESCRIPTION: <br />y � <br />❑ Zornng Distnct `', <br />❑Permitted Use? <br />This project is a new building or structure. <br />This project is an addition/alteration to an existing building or structure. <br />❑ Rural Address, <br />SANITARY SERVICE: <br />(new/eicistEng) ,=:u <br />EWER EPTIC <br />.. <br />❑ Welt, land/Ploodplain/ <br />HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br />Shoreland (attachment} ; <br />". <br />AREA TO NEAREST SQUARE FOOT: <br />(Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br />❑ ErosionControl,permit <br />SO LIISttlrb <br />(IeS,' <br />P <br />BASEMENT <br />1STFLOOR:anCe} <br />j TOTAL SQUARE FOOTAGE: j <br />filling/access) } `! <br />2ND FLOOR: <br />3RD FLOOR: <br />❑. Review Location Survey -,. <br />and available options �:� <br />ESTIMATED CONSTRUCTION COST:-► <br />(Please round to nearest dollar) <br />--► <br />1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? .......... <br />2. Is there a wetland or floodplain on or near the property? ........................................... <br />3. Have you talked with the township about your project and are they in agreement? ... <br />4. Has there been a.zoning permit issued for this property in the past 5 years? ............ <br />5. Is this project associated with a rezone/CUP/variance (petition/appeal # ) <br />6. Is a location survey required? (see reverse) .................................................... <br />7. Is this to correct a violation?............................................................................. <br />545112 (8109) <br />Des <br />[]No QDon't know <br />QYes <br />[-]No Don't know <br />Yes <br />[:]No <br />Dyes <br />[:]No <br />(leave blank if none) <br />QYes <br />QNo QDon't know <br />aes <br />QNo <br />APPLICATION MUST BE SIGNED <br />(Continue on Back) -► -► -+ <br />