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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 /> Cl2.EEK �?Lbge 7414'^'` ZZ C., ❑Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> 3 S� <br /> t�r c} Deed Restriction; CSM <br /> °`d w Anti Variance(# ) <br /> HOME PHONE , PHONE E-MAIL ADDRESS <br /> /-8/- ,� 3l/is $/S-S¢33//r- El Site Plan drawn to scale <br /> AGENT INFORMATION 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 0 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.dlane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> ❑PARCEL fronts a drawn to scale. <br /> NUMBER C•Z.F/Ob /D —301 '?Gal-0 A-A- .2 3k, A-cites g <br /> TOWNSHIP: SECTION: <br /> U,j /4: ,/1/4; ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> 4 •43 SC/ItIel.oitol <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> Hot,sC 544o ❑ Zoning District <br /> El This 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 /> FIEWER 1)EPTIC (new/existing) <br /> HEIGHT IN FEET NUMBER OF STORIES: (Not including basement) <br /> ❑ Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: 1—, <br /> ErosionControl permit <br /> 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> LOO L <br /> UU ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ --► ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) / 00 0 <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 /> 2. Is there a wetland or floodplain on or near the property? Elves ao ElDon't know <br /> 3. Have you talked with the township about your project and are they in agreement? Dies 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 No ❑Don't know <br /> 7. Is this to correct a violation? Ives ON <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) —► —► —► <br />