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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER OWNER i.4.14E ,/ <br /> 4fo✓t I/ 4-S ❑Zoning Status;CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) Deed Restriction;CSM <br /> lie 3- T. Ve/••—•‘ A(04.• 14-•e""l. W Z 53 5°/ 3 Variance(# ) <br /> HOME PHONE ELL PHONE E-MAIL ADDRESS ,/ <br /> �i.01 3s7-01 9y 0�s«� �i 4 Ave,' •0) ❑Site Plan drawn to scale <br /> AGENT INFORMATION I CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> ['Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS, of well/septic <br /> �, Z) ,/� .''1 ❑ <br /> (City,State,Zip) Av 0 (City,State,Zip) 45 P Setbacks <br /> iv <br /> PHONE PHONE ❑Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) ❑Elevation of property <br /> ElPARCEL PARCEL NUMBER: CURRENT NI ACREAGE: <br /> PARCEL 0r 4OOr,1/1,9,40("7 0- + frontage drawn to scale. <br /> NUMBER <br /> TOWNSHIP: SECTIO <br /> ICroAek /9...- <br /> '/4: '/4'/4: ❑ Driveway permits <br /> (state,county,town) <br /> ADDRESS: 5 // A <br /> CSM: LOT SUBDIVISION'! BLOCK/LOT El Sanitary permits <br /> 0743( 4( (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 5 ,M(t 41.4,i,11 uoM4t. ❑ Zoning District <br /> U This project is a new building or structure. ❑ Permitted Use? <br /> his project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> EWER WEPTIC 13-a,(s _o00 3 6 (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 /> ❑ ErosionControfpermit <br /> BASEMENT 1ST FLOOR: 0e ,1l 1 <br /> 33'/,0 i J 6y I ,�, TOTAL SQUARE FOOTAGE: (slopes,disturbance, <br /> 330 filling/access) <br /> 2ND FLOOR: zRBft .--- &IV l( / `L1 7. <br /> 5 /3Y ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ ♦ ♦ ♦ ♦ ♦ and availableoptions.. <br /> (Please round to nearest dollar) L 00,o p o <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? L(es EVo ['Don't know <br /> 2. Is there a wetland or floodplain on or near the property? Yes ❑No ODon't know <br /> 3. Have you talked with the township about your project and are they in agreement'? 11Yes ENo <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? Dies No <br /> 5. Is this project associated with a rezone/CUPNariance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) [Yes 'lo EDon't know <br /> 7. Is this to correct a violation? ❑Yes �]0 No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► <br /> 545-112(4/08) <br />