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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 /> c?Off l. n) . <br /> OWNER ADDRESS (Number,Street,City,State,Zip) ❑Zoning Status; CUP; <br /> ?-' 1 2 rn�ZR St Rd. Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE 'CELL PHONE E-MAIL ADDRESS <br /> 60-345. 03 0 tore` C3cri OS @ /4 c e W\ El Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> God El Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 01412. i ii- cl' 0 <br /> (City,State,Zip) (City,State,Zip) El Setbacks <br /> /WOW 1- o u ' -35 0Z- <br /> PHONE PHONE ❑Site Plan approval from <br /> 6 ac-8 PIS 039$ applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> OA, 0197 US ❑ Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.usn ❑ Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: <br /> ❑PARCEL 062.04-2`$4_vZ,1,4 R,I-- 1 .. qc frontage drawn to scale. <br /> NUMBER O 0 0 Tu (C Il T <br /> TOWNSHIP: SECTI`ON: <br /> eR ON A � ,/4: ,/4,/: ❑ Driveway permits <br /> ADDRESS: y (state,county,town) <br /> rngo L Z MAN ANA-14.--N br. VQRONA1 WI• 53 43 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> 02_190 2, (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> J S ) N 9 k T A M■Ly ❑ Zoning District <br /> . [IThis project is a new building structure. 11 L7 Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER [EPTIC /3 - 20/g- ©oo3 (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basemen!) <br /> 30' ❑ 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: 1 ST FLOOR: ❑ <br /> ErosionControl permit <br /> iQ 77 V/6 L, 4, TOTAL SQUARE FOOTAGE: 4, (slopes,disturbance, <br /> (� filling/access) <br /> 2ND FLOOR: ��� 3RD FLOOR: 9 �7-/ <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ jo0/fl 00• <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes LX No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes EINo ['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 ®No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes No <br /> I 6-, APPLICATION MUST BE SIGNED <br /> 545-112(4/08) <br /> (Continue on Back) —► ■ —► <br />