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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME � 4/i1C ` ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number!Street,City,State,Zip) Deed Restriction; CSM <br /> /560 5T4. � /q' ,44.4.,s4-11 w1' 3-35-3-p Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> to— q37 d o;3z/ffos /a 1- K c�Tht t.O .Gm✓h ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) ❑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.us/) ❑Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> '/a: WA: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF Review <br /> PROJECT DESCRIPTION: <br /> ❑ Zoning District <br /> . ❑This project is a new building or structure. Cl Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT 1ST FLOOR: ❑ ErostonControl permit <br /> 4, TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ -i ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Eves ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Elves ON ❑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 OW <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? Elves ❑No <br /> • APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► -- —+ <br /> 545-112(4108) <br />