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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 /> mss N1/es <br /> ❑Zoning Status; CUP; <br /> OWNER ADD ESS (Number,Street,City,State,Zip) Deed Restri I ; CSM <br /> (99'0/J c r H K. <br /> M d i le To.r WJt s--s Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 0=- , -3 D(O .Q F-6-1s--,5-a00 r e rJ ptr e5 cif u0 i ritc r , C O M ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includVA dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Ripe ❑Site Plan ingluding location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/sepplic <br /> (City,State,Zip) (City,State,Zip) ❑Setbyks <br /> PHONE PHONE ❑Site Plan a proval from <br /> applicako iship. <br /> E-MAIL ADDRESS E-MAIL ADDRESS ,, <br /> ❑Floor plans scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation off pr erty <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> PARCEL C/ r� / frontage dr' to scale. <br /> NUMBER OS�7 O�I�(- ^�SGQ'�p �' - / A=x yU g <br /> TOWNSHIP: SECTION: <br /> t O 1C a by atA. 1/4: . 'sit- /4'/4: ❑Driveway e is <br /> (State,co ) <br /> ADDRESS: <br /> t / ❑Sanitary permits rr <br /> . <br /> CSM: LOT SUBDIVISION BLOCK/LOT NO(public,private) � 17 <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> FO 1-C._ &grm D r Arm Eoct,) ,i4,e.w i ❑ Zoning D1 ict <br /> . ❑This project is a new building or structure. ❑ Permitte(Jse? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Addr ss <br /> EWER [)EPTIC (new/exi in ) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> C3'4// ❑ Wetland/ loud I ' / <br /> Shoreland cent) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1 ST FL OR: <br /> ❑ ErosionControl permit <br /> o ? 6 4, TOTAL SQUARE FOOTAGE: 4, (slopes, is copy /�� <br /> VV�� V filling/a ✓)t t �` <br /> 2ND FLOOR: 3RD FLOOR: <br /> (illa 0 yo ❑ Review Location urvey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ --► and availab tions. <br /> (Please round to nearest dollar) /00 6 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ®Yes ❑No ['Don't know <br /> ?. Is there a wetland or floodplain on or near the property? ❑Yes o ❑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 ®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 ENo ❑Don't know <br /> ea, '. Is this to correct a violation? ❑Yes 'No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -s -♦ <br /> 545-112(4/08) <br />