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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> OWNER NAME II <br /> %ckgo:l L 124 tce r" ❑ Zoning Status; CUP; <br /> OWNER ADDRESS (Number,Street,City,State,Zip) <br /> l Deed Restriction; CSM <br /> 1-1-'3(0 S c o Lf y R,Al - \r 1 W ,-A s o r L✓-T_ c 3 s�l d Variance(# ) <br /> HOME PHONE CELL PHONE E-MAIL ADDRESS <br /> (,o8-8 7-- 20 C-1 (0a- 6c,-4321 41 o-60(0 yc I-oo • c'a^^ ❑ 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 /> (City,State,Zip) (City,State,Zip) ❑ Setbacks <br /> PHONE PHONE ❑ Site Plan approval from <br /> applicable township. <br /> E-MAIL ADDRESS E-MAIL ADDRESS <br /> LI 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 , Z frontage drawn to scale. <br /> / <br /> NUMBER OtoR 0910-2-c!)-L2/60-19 V-� <br /> TOWNSHIP: SECTION: <br /> 1/11A: ❑ Driveway permits <br /> LA__)` d s 4, /4. (state,county,town)■ <br /> ADDRESS: <br /> 11'3bS S, 0L) d R, 1gc �rI 1J,-,ccc - w-- C3-C-9 ❑ Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT (public, private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: <br /> 20 x 1 it -1),,G k ❑ Zoning District <br /> . A This project is a new building or structure. LI Permitted Use? <br /> l This project is an addition/alteration to an existing building or structure. <br /> SANITARY SERVICE: PERMIT NUMBER: ❑ Rural Address <br /> AI SEWER ❑SEPTIC (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) 1—, ErosionControl permit <br /> BASEMENT: 1ST FLOOR: <br /> 2- d ,l TOTAL SQUARE FOOTAGE: ,$, (slopes,disturbance, <br /> filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: Q and available options. <br /> (Please round to nearest dollar) -� ♦ ♦ ♦ ♦ V 3 Lo d(7 U <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? ❑Yes LI No LI Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes ❑No ❑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 LI 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) ❑Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ❑Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> 545-112(4/08) I (Continue on Back) -♦ ♦ -► <br />