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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 /> e V e LO.C.N 1/1"0,`^ �� r� p Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> 3 1) 3 -r gaci-L,J icke 0r i L- Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> t2O6 . .l a-O t°4 tee. • j.44 . ®67 ex-a'/ ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> O(' O Z •`N kC)/ ■ ACS f ' f-{O✓A Va', \c�t',mac 4 ❑Site Plan including location <br /> AGENT ADDRESS tvl" CONTRACTOR ADDRESS �` of welUseptic <br /> - l■ � Lc-Fee r S-)- <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> DoMEOLTILE t.-.. c5 <br /> PHONE PHONE El 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/) <br /> PARENT PARCE UMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL Q 06 i o 1 g4285ocyi" p-1 _ Fr 3$ frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> 0t/4.-w w /? 1/a: g Mt: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> a-$601 L c I o r RC21 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> AC! 60s ❑ Zoning District <br /> . ZRhis project is a new building or structure. ❑ Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER T)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not induding basement) <br /> 1 I (Q l ❑ Wetland/Floodplain/ <br /> 1 Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: ❑ ErosionControl permit <br /> 4 TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: <br /> filling/access) <br /> ESTIMATED CONSTRUCTION COST: ell-/ ❑ Review available p Survey <br /> (Please round to nearest dollar) <br /> ♦ -.-∎ ♦ ♦ ♦ ♦ / 0 D(� and ailable options. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? DYes effRo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? [Yes alo ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? zs ❑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) Elves alo ['Don't know <br /> 7. Is this to correct a violation? Dyes Ftio <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) -► ♦ -4 <br />