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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME r , <br /> '"� % C i 'Q , < h 'e-Z. ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zi ) Deed Restriction; CSM <br /> 5 S ( E.' C.tJ ‘lft- 04 s&) Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> ?)Zg ^90 B ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> t°ViL2(wt/O Z(0,( 1/64e-4-- & 4,_ ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> c d / /304,F� t 4.Y S C:a d 4.t aa.c.,‘A c-€ U4--,1-,-( <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> t4sti s??e( //us-49 ---e ? e( <br /> PHONE PHONE ❑Site Plan approval from <br /> 2-7? -698? ( 2-? q—6 &? ( applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) El Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ON IN : ACREAGE' <br /> ❑NUM ER D-7'(}g Sit 13 2 U Ir — t /.-� frontage drawn to scale. <br /> TOWNSHIP: SECTIO : <br /> .Mt ckQd(-�,II) ---N ,/. ,/a,/a: ❑ Driveway permits <br /> ADDRESS: (/`l (state,county,town) <br /> 3 N R 1 LE F-Lon-e c 0,n,T- .%Ns(_t:.(-v..) <br /> CSM: LOT 2-0 (public,BLOCK/LOT ❑Sanitary permits <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT D C IPTION: <br /> S ❑ Zoning District <br /> . I his project is a new building or structure. ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. 77 <br /> SANITARY SERVICE: PERMIT NUMBER: 0 Rural Address <br /> FIEWER r3EPTIC 3 -Za t5 — c7O coO Z (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> 2O 1‘-- ❑ Wetland/Floodplain/ <br /> 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: <br /> ❑ ErosionControl permit <br /> s v O 2 /_O 6 + TOTAL SQUARE FOOTAGE: , (slopes,disturbance, <br /> G�CP filling/aCCeSS) <br /> 2ND FLOOR: 3RD FLOOR y / 0 Q Review Location Survey <br /> ESTIMATED CONSTRUCTION COST ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ 523- <br /> /40 U <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? Elves NNo ❑Don't know <br /> 2. 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? Wes o <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes glNo <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 EN ❑Don't know <br /> 7. Is this to correct a violation? [Yes Olo <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />