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ZONING PERMIT APPLICATION www.countyofdane.com <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> ',\\ \,vc, f n-'.v J •N o% M <br /> OWNER ADDRESS (Number,Street,City Stat ,Zip) �� `� ' ` DZoning Status; CUP; <br /> ) i`70 6% mhv1 l53-t1 �l� Ill --;3 (As Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> 0 4 -I 33D,9 b ,n ot Oh W S nti }.. vmv. `L m , :� Q Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGE1.1 NAME CONTRACTOR NAME <br /> Yr`k a 5 00°• n SO Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic lk.\) Z') <br /> (City,State,Zip) (City,State,Zip) [Setbacks <br /> PHONE PHONE ❑/Site Plap'pproval from <br /> apiplicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> D Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: URRENTZONI : ACREAGE; r ` If vation of property <br /> PARCEL o5 D rJ_, ©qN' g v /E LJ tage drawn to scale. <br /> NUMBER Q t1 / • <br /> TOWNSHIP: SECTI <br /> • <br /> ,/. .S E .—, eway permits 1 \ <br /> m 0 n)r{OSs? a/a. �, E stat <br /> A <br /> ) <br /> DDRESS: 1 / 7 "\ 1 ' l ��( e,county,is <br /> CSM: LOT SUBDIVISION BLOCK/LOT L� Sai,itary permits _ <br /> (publ , private) a r� <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <U <br /> V\Yfi Li Zoning District <br /> ©This project is a new building or structure. <br /> ermitted Use? <br /> This project is an additio al ration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ' k . Rural Address <br /> (SEWER E 7t & (e (new/existing) <br /> HEIGHT IN FEET: <br /> / 8 NUMBER OF STORIES: (Not including basement) <br /> 1 ❑ Wetland/F000dplain/ <br /> AREA TO NEAREST SQUARE FOOT: 3(o- ) <br /> Shoreland (attachment) <br /> (Outside dimensions including unfinished area, attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: l // ❑ ErosionControl permit <br /> / ��V 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> I �J filling/access) <br /> 2ND FLOOR: 3RD FLOOR: Y L/VO/ ❑ Review Location Survey \� <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ i I /�1 , - and available options. <br /> (Please round to nearest dollar) 0 <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 111Yes Ej No 0 Don't know <br /> 2. Is there a wetland or floodplain on or near the property? fl Yes gi No ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? QYes ❑No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? El Yes El No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal#t;: 121‘ ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) !Yes M No n Don't know <br /> 7. Is this to correct a violation? [Yes 0 No <br /> i .\... C ‘ <br /> I APPLICATION MUST BE SIGNED <br /> 545-112(aioa) <br /> (Continue on Back) ♦ ■ -♦ <br />