Laserfiche WebLink
T\ 100 <br /> ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME <br /> a r\`. Q- ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS t <br /> -1 t°� — \l4°■3 Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> A NT NAME ^^-- � _QQ CONTRACTOR NAME <br /> a!?'/1 $3r{L uL` AVQI�' Y�tC-s -W.1 l aA .Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of welVseptic <br /> PS o S Sen►1-4)r ca U. 3223 vacrs4AN,Aszi s \-- <br /> (City,State,Zip) (City,State,Zip) 53 4 ❑Setbacks <br /> M c�.e o" w L 53 I Li vv�. olekL w \ -1' .-r 3 3 6 <br /> PHONE PHONE ❑Site Plan approval from <br /> a c—3L1 c.,/ S3(p—q6i.9 1 ,ko wn> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ��s ,•... ,,� , . A a ,k� , .tc scon.. ❑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 /> ❑PARCEL frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> IA: '/4'/4: ❑Driveway permits <br /> ADDRESS: (state,county,town) <br /> L0&()S SR-'-t4/a al 9-1 <br /> CSM: LOT SUBDIVISION BLOCK/LOT ❑Sanitary permits <br /> (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> ‘kQ1Y%c S'5" \ Pun.,e,k ❑ Zoning District <br /> [This This project is a new building or structure. f ❑ Permitted Use? <br /> This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> FIEWER r)EPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> rt <br /> 1 1-1t)\ •r2`GI'• (1 3 ❑ Wetland/Floodplain/ <br /> /l/ Shoreland (attachment) <br /> AREA TO NEAREST SQUARE FOOT: <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1STFLOO ❑ EroslonControl permit <br /> b'0 j TOTAL SQUARE FOOTAGE: j (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and available options. <br /> (Please round to nearest dollar) $ <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? ❑Yes Jlo ['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) ❑ D.Yes � ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ONo <br /> A10 �/�/� r^ APPLICATION MUST BE SIGNED <br /> 545-112(4/08) ' `10 ` "° V'� �)Aa/r V \ a.. (Continue on Back) -♦ ■ -♦ <br /> 1N a C , v\. 5 <br />