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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> Own, - . •E t <br /> • • J-•• A i _� ❑Zoning Status;CUP; <br /> OWNER AI TRESS (Num. r,Str:-t,City,St ip) <br /> —7 Lf( ' Q._-, �c- Deed Restriction;CSM <br /> Variance(# ) <br /> HOME• ONE CELL PHONE E-MAIL ADDRESS i <br /> .._4 _ ti I a • GY‘Orv3 , e ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT AME CONTRACTOR NAME <br /> I a-c.... ,J, i�a.r c ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 7O333r ia.r 4.4t.n <br /> (City,State,Zip) (Ci State,Zip ❑Setbacks <br /> W <br /> C�✓l ('0.\C\ <br /> %SSA <br /> PHONE PHONE i ❑Site Plan approval from <br /> (re 15 applicable township. <br /> E-MAIL ADDRESS -MAILA ESS <br /> t <br /> � � �'�o I ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.diane.wi.usi) <br /> PARENT ip'•;'�:;• • .''! ' ° : d..p RENT ZONING: ACREAGE: <br /> ❑Elevation of property <br /> PARCEL _ frontage drawn to scale. <br /> NUMBER •��v���$ri.3(�� • �1 $g <br /> TOWNSHIP: S C 10� � <br /> P 2 iN G it- t Lb IA: '/e'/4: El Driveway permits <br /> ADDRESS: nn (state,county,town) <br /> "7 y/ ¶ /`1/e c P4 ❑Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C7 o . -c-_ e- ❑ Zoning District <br /> . This project is a n4 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 /> [EWER rEPTIC (new/existing) <br /> HEIGHT IN FEETF ^ NUMBER OF STORIES: (Not including basement) <br /> J� '-1 `� t i ❑ Wetland/Floodplain/ <br /> I 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 /> O I� c O e + TOTAL SQUARE FOOTAGE: IF (SIOpeSFd1StUrbance, <br /> 7 -'j' filling/aOcetsj <br /> 2ND FLOOR: 3RD FLOOR: Q-Go <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: f� and available C h one. <br /> (Please round to nearest dollar) ♦ ♦ ♦ ♦ ♦ ♦ 40--.40, 0. <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑YesVo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? DYes ❑Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? �' 'es No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ['Yes ` Vo <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 ❑Don't know <br /> 7. Is this to correct a violation? nYes to <br /> 1A6 APPLICATION MUST BE SIGNED <br /> 545-112(4/08) (Continue on Back) <br />