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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App#fi XL(3.- <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNE. LAME /j <br /> /{.e 2(2— g 4 t f'e it) DCning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction; CSM <br /> (-/`3 ? (mac..) C., od 1 e- /` , L. , Slake W t S`3527 Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> a'- 22.s-/w? Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> (City,State,Zip) (City,State,Zip) 1=ietbacks <br /> PHONE PHONE IQ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑ <br /> / Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wLus/) Elevation of property <br /> PARENT PARCEL NUMBER: CURRENT ZONING: ACREAGE: p p y <br /> ElPARCEL _� ^� (7 m frontage drawn to scale.O 10 7 <br /> NUMBER 3� <br /> TOWNSHIP: SECTION: <br /> (2 0 Y b w, ,/4: , IA: Driveway permits <br /> ADDRESS: 7 ( te,county,town) <br /> (0 4'37 ( )0 1 •-Z4 (nC-L ��o ■-c-e w� _S-3 s y S <br /> CSM: LOT SUBDIVISION BLOCK/LOT Sanitary permits <br /> / o Z 9A 3 .5 y / 4,v U ? (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> i 7" S Q s o z>` jZis2 O ` IZoning District <br /> . ['This project is a new building or structure. il Permitted Use? <br /> II.This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: Si Rural ' •• tss <br /> FIEWER YYYYYY''�����EPTIC (new/ !) <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: 1ST FLOOR: ErosionControl permit <br /> ---_---- i U% 4, TOTAL SQUARE FOOTAGE: ,, (slopes,disturbance, <br /> 2ND FLOOR: 3RD FLOOR: filling/access) <br /> 1 ti Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ af,�� and available options. <br /> (Please round to nearest dollar) D <br /> P <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? t� ®ales tENo ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ENo ['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? [ales ao <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? Efres No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) -♦ <br /> 545-112(4/08) <br />