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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 /> pops 6-oOBfifiko J3 LL-L. ❑Zoning Status; CUP; <br /> OWN ADDRESS (Number,Street,City,State,Zip) , Deed Restriction; CSM <br /> �`� /0�{'c EI_ a) t,11�b t--L-/bkI/ fit)/ 53.5b.-2_ Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> A C63 (08-7/2- `f rcc 44 a l e M ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions A AGENT NAME CONTRACTOR NAME <br /> G _A SM l-1'4, ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR A RES of well/septic <br /> '/&7 TOE. P F RJ <br /> (City,State,Zip) (City,State,Zip) ❑Setbacks <br /> M MD/ E U ) wi 5.35b-< <br /> PHONE PHONE ❑Site Plan approval from <br /> bi\115 �iog-19$-•6Z0"7 applicable township. <br /> AILADD ESS J� E-MAIL ADDRESS <br /> # r4,/crIC4101a5r1[-4AiQ- 1lR1't C.X)n''t Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: ❑Elevation of property <br /> Q p���,� / [ frontage drawn to scale. <br /> ❑NUMBER6L�ZOZ-C7n�v-� � l' � �� <br /> TOWNSHIP: SECTIO : <br /> BLACK �,A R-T ZO %.. Nt '/4'/4: ❑Driveway permits <br /> ADDRESS: (state, county,town) <br /> 5-55(2 MANocKt-R f i MN2- r<�o I El iJ i 53560 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> C x P S i O M OF A p-Eck ❑ Zoning District <br /> . ❑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 /> W <br /> EER KEPTIC 1N+ (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> ❑ 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 /> TOTAL SQUARE FOOTAGE: + (slopes,disturbance, <br /> 3RD FLOOR: <br /> filling/access) <br /> 2ND FLOOR: <br /> q7 o �� <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ ?�('�, and available options. <br /> (Please round to nearest dollar) I ) vV <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? [Yes ZNo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Eyes 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? Efres ANo <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 0 o [Don't know <br /> 7. Is this to correct a violation? ❑Yes o <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -+ ♦ -4 <br /> 545-112(4/08) <br />