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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 /> ?L 1.0 k€z L L55-e t/ 0 Zoning Status;CUP; <br /> O(NNERADDRESS (Number,Street,City,State,Zip) ,�, rr Deed Restriction; CSM <br /> Care I E�(/c� f e 0« ((e"C I ,_ t-e'C,r\ -5 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS 5 3 5 CJ--- <br /> /` 7 . -2 a ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ri I I ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> P 'el `4 a3ciJ-b`� <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> t'1 erct a LAA 5 5 3 'De-a <br /> PHONE PHONE ['Site Plan approval from <br /> 5(1 5 - CL-70 applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> 0 Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT CURRENT ZONING: ACREAGE: frontage drawn to scale.❑NUMBER b ` 6 `I _.�,GO-5 r j <br /> TOWNSHIP: SECTION: ❑Driveway permits <br /> r r — 1/4:1/44: 1/41/4:1/4a' (state,county,town) <br /> ADDRESS: r. <br /> (g 6, / f n e Lioc'7 t-,l ,-0 ( i f e.,2 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: CI zoning District <br /> et c-�1,° 5 ed <br /> . gniis project is a new building or structure. 0 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> (new/existing) <br /> FIEWER �EPTIC <br /> HEI HT IN FEET: �Y '' NUMBER OF STORIES: (Not including basement) Wettand/FIoOd�?laiN <br /> �� ( Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) LI ErosionControl permit <br /> BASEMENT: 1ST FLOOR: l(slopes,disturbance, <br /> l TOTAL SQUARE FOOTAGE: + S oP <br /> Q O filling/access) <br /> 2ND FLOOR: 3RD FLOOR: Lk,(// 1/ 0 Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ -► ♦ $ // r/ / and available options. <br /> (Please round to nearest dollar) (� E� <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes '-: No QDon't know <br /> 2. Is there a wetland or floodplain on or near the property? Eves W( o QDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? -.- Yes Ili o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Eves NSNo <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) <br /> (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ❑1'es to ❑Don't know <br /> 7. Is this to correct a violation? DYes ligga <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />